Intravenous Antimicrobial Agents Research Articles

Feasibility, Effectiveness and Safety of Elastomeric Pumps for Delivery of Antibiotics to Adult Hospital Inpatients-A Systematic Review.

Elastomeric infusion pumps (EMPs) have been implemented in many fields, including analgesia, chemotherapy and cardiology. Their application in antimicrobials is mainly limited to the outpatient setting, but with a need to optimise inpatient antimicrobial treatment, the use of EMPs presents a potential option. This review aimed to identify if the use of EMPs within an inpatient setting is feasible, effective and safe for antimicrobial use. Criteria for inclusion were human studies that involved the treatment of an infection with intravenous antimicrobial agents via an EMP. A search strategy was developed covering both the indexed and grey literature, with all study designs included. The review found 1 eligible study enrolling 6 patients. There was strong patient preference for EMPs (6/6), and daily tasks were easily completed whilst attached to the EMP. Nurses (5/5) also preffered the pumps, and the majority reported them as easy to use. The review has identified the need for further research in the area. Evidence for the use of EMPs to administer antibiotics in the inpatient setting is scarce, and more work is needed to understand the advantages to patients, to healthcare workers and from an antimicrobial stewardship perspective. Potential disadvantages that may put patients at risk also need investigating.

Management of fever and acute painful crises in children with sickle cell disease in emergency departments: a tertiary hospital experience.

Sickle Cell Disease (SCD) is highly prevalent in Saudi Arabia with variable demographics and access to health care facilities including emergency departments. Literature reviews for locally published articles are deficient in the in-depth evaluation of current emergency practices in managing patients with SCD. The study aims to assess the current emergency practice in managing SCD patients in tertiary hospitals. We reviewed data of 212 visits by patients with SCD over three years and assessed the current emergency department practices in managing common SCD crises, such as vaso-occlusive (VOC) and febrile episodes. Our findings revealed that 47.2%, 37.7%, and 15% of the patients presented with pain, fever, or both, respectively. The patients were triaged level III according to the Canadian triage and acuity scale system in 89% of the visits. The Median time for patients to see healthcare providers was 22 min. In the first 2 h, 86% of the patients received at least one fluid bolus and 79% of them received appropriate analgesia for pain crises. Approximately 41.5% of the patients with fever were admitted and received ceftriaxone as single intravenous antimicrobial agent. However, none of the patients had bacteremia. Only 2.4% of the patients had either urinary tract infection or osteomyelitis based on imaging. ED management is a key factor in the successful management of patients with SCD in a timely manner by providing fluids, analgesia, and antibiotics. Adopting evidence-based guidelines and avoiding unnecessary admissions are suggested in clinically well patients with fever in the era of completed vaccination, antibiotic prophylaxis, and good access to care for patients with a clear viral infection focus.

Clinical Spectrum and Treatment Response of Malignant Otitis Externa Patients: A Rural Tertiary Care Centre Experience.

Malignant otitis externa (MOE) is an invasive external ear infection that has a tendency to spread throughthe temporal bone and can further progress to involve intracranial structures. Though the prevalence of MOE is rare, high morbidity and mortality are often associated. Complications of advanced MOE include cranial nerve involvement, most commonly facial nerve, and intracranial infections such as abscesses and meningitis. In this retrospective case series of nine patients diagnosed with MOE, demographic data, clinical presentations, laboratory data, and radiological findings were reviewed. All patients were followed up for a minimum period of three months after discharge. Outcomes were measured in terms of reduction in obnoxious ear pain (Visual Analogue Scale), ear discharge, tinnitus, need for re-hospitalization, recurrence of disease, and overall survival. In our case series of nine patients (seven males and two females), six underwent surgery, and three patients were managed with a medical line of treatment. All patients had a significant reduction in otorrhea, otalgia, random venous blood sugars, and improvement of facial palsy implicating good response to treatment. Prompt diagnosis of MOE warrants clinical expertise and aids in preventing complications. A prolonged course of intravenous anti-microbial agents is the mainstay of treatment, but timely surgical interventions in treatment-resistant cases can prevent complications.

Investigation of Bacterial Isolations and Antimicrobial Susceptibility of Chronic Rhinitis in Cats.

Simple SummaryAlthough rhinitis is a quite common disease in cats, the underlying cause is not easily explored. In addition to responding to the emerging concern regarding antimicrobial resistance and close contact between a pet and its owner, this study investigated bacterial identification and antimicrobial susceptibility in chronic rhinitis in cats. The current study found that rhinitis was more likely in younger and young adult cats, with Pseudomonas spp. being the main bacterial species, as well as multidrug-resistant, followed by Pasteurella spp., Staphylococcus spp., and E. coli. Overall, amikacin, imipenem, and meropenem, which are intravenous antimicrobial agents, exhibited high activity against most bacterial species. However, the use of antimicrobials in categories A and B (EMA) in companion animals are not recommended if other antimicrobial choices are available. Notably, this report reflects on the current antimicrobial resistance situation. Therefore, the appropriate antimicrobial usage and selected drugs should be based on antimicrobial use guidelines, the result of culture, and antimicrobial susceptibility.Chronic rhinitis is a quite common upper respiratory tract (URT) disease in cats. As a result of unclear etiology, frequently, multidrug-resistant bacteria are identified. This study investigated bacterial isolations and an antimicrobial susceptibility test (AST) in chronic rhinitis in cats. The medical records of 395 cats with chronic URT signs were reviewed at the Kasetsart University Veterinary Teaching Hospital (KUVTH) between 2016 and 2021 to survey the underlying causes of URT. Then, apart from rhinitis, other causes were excluded to identify the bacterial species and antimicrobial susceptibility. The results indicated that the most frequent finding was neoplasia, followed by rhinitis and anatomical defects. Furthermore, the only significant association was between the age range and disease group, with gender, FIV, or FeLV infection not being significant. Rhinitis was 4.7 times more likely to occur than neoplasia in younger and young adult cats in the age range < 1–3 years compared to the group > 10 years. The main bacterial species was the Pseudomonas species. Antimicrobials with a susceptibility rate of more than 90% were amikacin, gentamicin, ciprofloxacin, norfloxacin, marbofloxacin, imipenem, and meropenem. In conclusion, rhinitis was the second most common chronic URT disease in cats and was more common in younger and young adult cats. The predominant bacteria with AST in this study reflect the antimicrobial resistance situation. Thus, antimicrobial usage should follow antimicrobial use guidelines first.

Proactive discontinuation of postoperative antibiotic prophylaxis after urethroplasty.

We aimed to examine the clinical significance of an antimicrobial administration protocol, in which postoperative prophylaxis was proactively discontinued. We included 81 adult urethroplasties performed at our institution in the study. Preoperative bacteriuria was treated using an appropriate antimicrobial agent 2-5 days before surgery. All patients were treated with intravenous antimicrobial agents until postoperative day 2, and thereafter without prophylaxis. Antibiotics were resumed from the day before the urethrogram for urethral catheter removal, 2-3 weeks postoperatively. The relationships between pre- and postoperative positive urine culture and postoperative infectious complications, along with factors influencing surgical success rate were examined retrospectively. Of the 81 patients, 60 underwent anastomotic repair and 21 underwent substitution repair. Positive preoperative urine cultures were more frequent in patients having suprapubic cystostomy tube than in those without (P < 0.0001), but such a difference was not noted postoperatively between the two groups, and approximately half of the patients had a positive urine culture postoperatively. Wound infections and symptomatic urinary tract infections rates were 3.7% and 2.5%, respectively, similar to previous studies with longer prophylaxis, and no significant correlation was noted with pre- and postoperative positive urine culture, treated by this antibiotic protocol. The overall clinical and objective success rates were 96.3% and 79.0%, respectively, and no significant impact of pre- or postoperative positive urine culture was noted. The only significant parameter for objective success was patient age. Perioperative management of urethroplasty is feasible using the antimicrobial protocol described in this study.

Comparison of Preparation Times and Cost for Compounded, Outsourced and Premixed Vancomycin Products in a Long-Term Care Pharmacy

Multiple drug resistant organism (MDRO) infections are increasingly being treated in post-acute long-term care (PA-LTC) settings, due to high costs associated with treating MDRO in the hospital. While MDRO therapies are increasingly given in PA-LTC settings, studies suggest PA-LTCs may also be a reservoir of MDROs, perhaps more so than hospital settings. Intravenous antimicrobial agents effective against MDRO, such as vancomycin, must increasingly be provisioned to PA-LTC settings, but preparation time and cost of provisioning vancomycin is not well characterized in the literature.

Safety of prolonged outpatient courses of intravenous antibiotics: a prospective cohort study

ObjectivesThe perceived need for prolonged intravenous antibiotic courses has become a major driver behind the growth of outpatient parenteral antimicrobial therapy (OPAT) services. Several recent randomized controlled trials demonstrate noninferiority of an early switch to oral therapy and highlight the need to accurately quantify harms associated with OPAT. MethodsWe conducted a 10-year prospective cohort study in a tertiary hospital OPAT service. Adults admitted to the service between 1 June 2009 and 30 June 2019 who received an intravenous antimicrobial agent were included. Adverse events (AEs) attributable to intravenous antibiotics or intravenous access were recorded in a prospectively maintained database and analyzed. ResultsThere were 4160 admissions (median length of stay: 20 days) and a total of 88 432 patient-days of observation; 135 patients (3.3% of admissions) experienced at least one major AE (1.54 per 1000 patient-days; 95% CI, 1.29–1.82). The risk of a major AE peaked in the second week of OPAT admission, with acute kidney injury (43 of 136; 32%) and severe cytopenia (42 of 136; 31%) being the most common. At least one minor AE occurred in 38.3% of admissions (1592 of 4160; 26.4 per 1000 patient-days; 95% CI, 25.4–27.5), with central venous catheter-related complications accounting for 71% of AEs (1658 of 2338). DiscussionThe incidence of major AEs during long courses of intravenous antibiotics is low, peaking in week 2 and tailing off thereafter. These results should inform decisions concerning the choice of intravenous versus oral antimicrobials.

Intra Ventricular Colistin in Neonatal Brain Abscess Management: A Case of Multiple Brain Abscesses

Neonatal Brain abscess is a rare sever neonatal infection requiring careful medical and neurosurgical intervention strategies to reduce morbidity and mortality rates. Gram-negative bacterial agents are the most common pathogens involved in brain abscesses of neonates. The use of wide spectrum antibiotics in combination with neurosurgical drainage of abscesses larger than 2.5 cm is the mainstay of treatment. Colistin is a polymyxin antibiotic used to treat bacterial infections caused by susceptible gram-negative bacteria but with a limited penetration in blood brain barrier. However, there is limited data on using intraventricular Colistin in neonatal intracranial infections. A 12-day-old male neonate with multiple brain abscesses in frontal and parietal lobes is presented. The abscesses were successfully managed with a combination of intravenous antimicrobial agents, intraventricular Colistin and concurrent administration of Interferon-ɣ. Subsequently, he developed ventriculomegaly which was successfully managed by endoscopic third ventriculostomy. He had an acceptable neurologic outcome. Due to reduced penetration of colistin in blood brain barrier, use of intraventricular Colistin in combination with its intravenous form can be beneficial in management of neonatal brain abscesses. Concurrent administration of Interferon-ɣ may improve the treatment process and outcome given that reduced secretion of this agent by neonatal T lymphocytes may contribute to a partial immunodeficiency state at this period of life.

Radiologic Findings of Splenic Abscess: A Report of Two Cases

Splenic abscess is a very rare entity with an incidence of about 0.14-0.7% in autopsy studies. Splenic abscess has been reported to have a mortality rate of about47%, it has various causes but usually associated with trauma and infections of the spleen. We report two cases of splenic abscess; a child with post traumatic cause and a middle aged lady with an unknown cause. Both cases were diagnosed of having the abscess following imaging; the first case had abdominopelvic ultrasound that showed an abscess cavity with a volume of about 11mls and subsequently resolved following medical treatment with intravenous antimicrobial agents. The second case however had an abdominopelvic computed tomography scan that showed a huge splenic abscess with a volume of about 1400mls; she had a successful splenectomy. We report the radiologic findings of these cases due to the rare nature of splenic abscess as reported in the literature.

Various Neurological Symptoms Associated with Infected Internal Iliac Artery Aneurysm: A Case Report.

A 68-year-old man presented with a chief complaint of left leg pain; he was later diagnosed with an infected left internal iliac artery aneurysm. Multiple mononeuropathy was suspected. Since the aneurysm had a high risk of rupture, emergency Y-graft replacement was performed. Bacteroides vulgatus was then detected from the pus of the aneurysm. With continuous oral antimicrobial agents following intravenous antimicrobial agents, the patient was noted to have no recurrence. However, his leg pain symptoms continued postoperatively; thus, a supporting device was needed. It should be noted that even neurological symptoms may indicate the presence of aortoiliac aneurysms.

The Impact of Anti-Microbial Drug-Drug Interactions on Acute Kidney Injury after Allogeneic Hematopoietic Cell Transplantation

Introduction: Acute kidney injury (AKI) is one of the major complications after allogeneic hematopoietic cell transplantation (allo-HCT), and several studies have demonstrated a relationship between poor outcome and the concomitant AKI in the early phase after allo-HCT. Among various post-transplant factors, usage of antimicrobial agents, especially in cases where multiple agents are combined, may be one of the major causes of post-transplant AKI, due the potential nephrotoxicity of each agent and drug-drug interactions. An association between the combination of vancomycin (VCM) with piperacillin/tazobactam (PIPC/TAZ) and increased risk of developing AKI after allo-HCT has been reported; however, no reports have demonstrated the impact of other combinations on post-transplant AKI. Herein, we performed a retrospective analysis to compare the incidence of AKI according to selected antimicrobial agents, using a database with information covering the time-dependent administrative status of all the agents involved. Methods: We included patients with hematological malignancies who received allo-HCT between 2006 and 2018 in Kyoto University, Kyoto, Japan to evaluate the incidence and risk factors of AKI early after transplantation (before Day100). The incidence of AKI was defined according to Acute Kidney Injury Network (AKIN) classification and evaluated, considering early death as a competing risk. Administrative status of each antimicrobial agent was treated as a time-dependent covariate, and the synergetic effects on AKI by multiple agents in combination were evaluated as p for interaction. Results: In total, 465 transplant cases (416 patients) were included. The median age at HCT was 49 years old (range, 17-70). Among these, 104 cases received a related-donor transplant (64 patients received bone marrow and 40 peripheral-blood stem cell grafts), 207 received a transplant from unrelated donors, and 154 received a single-unit cord-blood transplant. The median value for pre-transplant serum creatinine (sCr) was 0.6 (range, 0.20-1.68). The cumulative incidence of AKI at Day100 was 40.0%, and overall survival (OS) at 3 years after HCT was 43.5% in patients with AKI while 70.9% in those without AKI (hazard ratio [HR] = 2.63, 95% confidence interval = 1.95-3.55, p &amp;lt; 0.01). Being male and having a higher pre-transplant sCr were significant risk factors for AKI (HR = 1.53, p &amp;lt; 0.01 and HR = 4.21, p &amp;lt; 0.01, respectively). After HCT, 34 types of oral or intravenous antimicrobial agents (17 antibiotics, 6 antivirals, and 11 antifungals) were utilized across the entire cohort. A higher incidence of AKI was significantly associated with the use of intravenous ciprofloxacin, foscarnet (FCN), ganciclovir (GCV), liposomal amphotericin B (L-AMB), meropenem (MEPM), PIPC/TAZ, and VCM (p &amp;lt; 0.05). Next, we investigated the synergistic impacts of using anti-pseudomonal antibiotics and anti-methicillin resistant staphylococcus aureus (MRSA) agents, because empiric treatment of febrile neutropenia after HCT often relies on this combination, i.e. CFPM, PIPC/TAZ, or MEPM in combination with VCM or teicoplanin (TEIC). As a result, sole administration of VCM was associated with a higher incidence of AKI; this effect was enhanced when VCM was used in combination with PIPC/TAZ (HR = 3.03, p &amp;lt; 0.01 for VCM without PIPC/TAZ; HR = 4.38, p &amp;lt; 0.01 for VCM with PIPC/TAZ), indicating the existence of interaction between VCM and PIPC/TAZ. However, for the concomitant use of VCM plus CFPM or MEPM, no synergistic interaction was observed with regard to the increased incidence of AKI. In addition, administration of TEIC alone and any combination used with TEIC were not associated with an increased risk of AKI. An increased risk of AKI was also confirmed for the combination of MEPM plus GCV or FCN, and GCV plus L-AMB. Conclusions: AKI was significantly associated with poorer OS, and specific antimicrobial combinations were suggested to increase the risk of AKI. Avoidance of such combinations should be considered to preserve renal function and to reduce AKI-related morbidity and mortality. Disclosures No relevant conflicts of interest to declare.

Risk of novel coronavirus 2019 transmission from children to caregivers: A case series.

World Health Organization (WHO) characterised coronavirus disease 2019 (COVID-19) as a pandemic on 11 March 2020.1 As of 5 April 2020, more than 1 133 000 confirmed cases have been documented globally.2 In China, the majority of reported cases were adults, while 0.9% were below 15 years of age.3 A recent systematic review showed that children have accounted for 1–5% of diagnosed COVID-19 cases.4 COVID-19 in children appears to be mild and mostly acquired by household exposures.4-6 The potential risk of transmission from infected children to adults is of concern due to prolonged detection of the SARS-CoV-2 RNA in respiratory specimens and faeces.6 We studied the possibility of transmission from infected children to their caregivers. The first three paediatric COVID-19 cases in Thailand were detected as part of epidemiologic investigations among three family clusters. Case 1 was a 6-year-old Chinese boy who travelled to Thailand with his family; the index case in this family was his grandmother who developed symptoms on day 2 after arrival in Thailand. Case 2 was a 4-year-old Thai girl; the index case was her father who reported occupational exposure to foreign tourists. Case 3 was an 8-year-old-Thai boy; the index case was his grandfather who developed symptoms on day 3 after returning from a 4-day trip to Japan. Nasopharyngeal and throat swabs obtained from the three cases were positive for SARS-CoV-2 RNA by real-time reverse-transcription polymerase chain reaction assays on 27 January (case 1), 7 February (case 2) and 25 February (case 3) 2020. WHO advises all confirmed COVID-19 cases, even mild cases, to be isolated in health facilities,7 and according to Thailand's containment policy, each child was therefore hospitalised individually in a negative pressure room; case 1 was isolated with his grandfather who was also infected with COVID-19, while cases 2 and 3 were isolated with their healthy caregivers. All children had very mild respiratory symptoms for 1 day before admission. No other symptoms were documented. Physical examinations revealed unremarkable. Complete blood counts and chest radiograph interpretations were as shown in Table 1. All children were administered only oral antihistamine; no intravenous fluids, oxygen therapy, antimicrobial agents or antipyretic drugs were administered. Their symptoms were resolved within a few days. No child had fever for the entire duration of their stay in the hospital; all were in good conditions and recovered uneventfully. During isolation in our hospital, children and their caregivers were advised to wash hands frequently and not share personal items. Surgical masks were provided to them, although compliance with the use of masks was observed to be poor. No other personal protective equipment was provided. Respiratory swabs were collected from each child on alternate days and tested sequentially for SARS-CoV-2 RNA. Children were allowed to be discharged when their swabs turned negative for SARS-CoV-2 RNA on 2 consecutive days; this happened on days 15, 23 and 27 of illness for cases 1, 2 and 3, respectively. To assess the possibility of transmission, nasopharyngeal and throat swabs from the caregivers of case 2 (grandmother, aged 53 years) and case 3 (mother, aged 32 years) were collected on day 1 of isolation, followed by weekly, and finally on the day of discharge with their children. Swabs were tested for SARS-CoV-2 RNA by real-time reverse-transcription polymerase chain reaction assays targeting the N and ORF1ab genes (limit of detection = 100 copies/mL). All respiratory swabs from both caregivers were negative and none of them developed any symptoms throughout the period of stay in the hospital, details as shown in Table 2. On follow up over the phone on day 14 after discharge, caregivers reported no symptoms. Concerns have been raised that children could possibly be a source of infection to adults.8, 9 While our study revealed no evidence of transmission from mildly ill, afebrile children to their caregivers despite prolonged positivity of the SARS-CoV-2 RNA in their respiratory specimens, our findings are consistent with WHO's recommendations for alternatively managing patients with mild COVID-19 disease at home.10 However, due to limited cases in our study, further research with larger sample size would be needed to better understand children's role in the transmission of COVID-19 to adults including their caregivers. The authors thank their dedicated health-care workers, children and their caregivers. The authors thank Dr Renu Madanlal Garg at the World Health Organization, Thailand and Dr Emily Bloss at the Thailand MOPH and US CDC collaboration for helping editing the manuscript.

Soluble HLA-G pre-transplant levels to identify the risk for development of infection in heart transplant recipients

Infection is still a leading cause of death during the first year after heart transplantation. We evaluated the pre-transplant levels of HLA (Human Leukocyte antigen) – G molecules as a means of identifying heart recipients at risk of serious infections. We prospectively analyzed 122 adult heart transplant (HT) recipients. Serum samples were collected beforetransplantation and analyzed for sHLA-G levels by ELISA assay. The clinical follow-up period lasted 5 years. Clinical outcomes were bacterial infections requiring intravenous anti-microbial agents, cytomegalovirus (CMV) disease, and fungal infections requiring therapy. We found that 39 patients (32%) developed at least 1 serious bacterial infection. Higher pre-transplant sHLA-G levels were a risk factor for serious infection (above median value 5.4 ng/ml; relative risk 3.70; 95% confidence interval 1.03–12.64; p = 0.043). Patients with high levels of pre-transplant sHLA-G are also characterized by a lower overall survival at 5 years (p = 0.017), with microbial infections as major causes of death. No association was observed with the development rejection episode. Early monitoring of sHLA-G molecules proved useful for the identification of heart recipients who are at risk of serious infections.

Interstitial pneumonitis in a castration-resistant prostate cancer patient receiving cabazitaxel after thoracic radiation therapy: a case report

BackgroundInterstitial pneumonitis is a rare reaction in a previously irradiated area of pulmonary or thoracic lesion after treatment with anticancer drugs such as taxanes.Case presentationA 66-year-old man presented with a fever and dyspnea after treatment with cabazitaxel for castration-resistant prostate cancer. He was treated with an intravenous broad-spectrum antimicrobial agent, however he complained of dyspnea and had a pulse oximetric saturation of 80% while breathing room air. The patients had been treated for bone metastases with 37.5 Gy to the thoracic spine (Th 7) as a local radiotherapy. Radiological images showed pulmonary interstitial opacities in the irradiated field of the both lungs. The steroid pulse therapy was started. The patient’s dyspnea disappeared and the interstitial opacities had also improved.ConclusionsThis report is a case of interstitial pneumonitis in a castration-resistant prostate cancer patient receiving cabazitaxel after thoracic radiation therapy.

2367. Infection Incidence and Utilization of Antimicrobials in Physician Office Infusion Centers (POICs)

BackgroundPOICs offer a controlled setting for safe and effective outpatient treatment of moderate to severe infections with intravenous antimicrobial agents (IVAA) and agents used in treatment of Clostridium difficile infection (CDI). These therapies are provided via in-office or home administration. This study provides an overview of nationwide incidence of outpatient infections and utilization of IVAAs through POICs.MethodsA retrospective review of our centralized database was conducted of patient infections and therapy courses provided in POICs nationally that included complete data for 2017. All patients receiving IVAAs and drugs for CDI were included, along with dose, frequency, duration and method of administration. Descriptive measures were used to analyze data.ResultsA total of 12,930 infections were treated in 10,136 patients during 2017 among 77 POICs. Of those, 41% were treated directly from the community setting, avoiding hospitalization. Age distribution was <18 years <1%, 18–65 years 63% and >65 years 36%. Infections comprised 11 major diagnostic groups, with 47 subgroups. The most common diagnoses treated were bone and joint (37%), skin and skin structure (23%), genitourinary (14%) and bacteremia/septicemia (8%). 101 patients (1%) were treated for CDI. Geographical distribution occurred in the Midwest, Northeast, South, and West portion of the United States, where diagnoses were similar for all areas except the Northeast. This area had a significantly lower incidence of bone and joint infections (P < 0.0001) and a higher incidence of genitourinary infections (P < 0.0001). Overall utilization included 52 different agents, with 98.5% antimicrobials, 1% antifungals and 0.5% antivirals. Ceftriaxone was the most frequently used antimicrobial representing 16% of the total use, followed by vancomycin (14.5%), daptomycin (14.2%) and ertapenem (11%). The most prevalent infections and utilization of respective drug therapy is noted in the table. ConclusionThis study provides an annual overview of outpatient infection incidence with the utilization of IVAAs and therapy for CDI. A wide range of moderate to severe infections were treated, often avoiding hospitalization. Treatment regimens were broad, utilizing a wide variety of drugs and enabling extensive patient management in the POIC setting.Disclosures L. J. Van Anglen, Merck & Co.: Grant Investigator, Research grant.

Monitoring of early humoral immunity to identify lung recipients at risk for development of serious infections: A multicenter prospective study.

Infection is still a leading cause of death during the first year after lung transplantation. We performed a multicenter study among teaching hospitals to assess monitoring of early humoral immunity as a means of identifying lung recipients at risk of serious infections. We prospectively analyzed 82 adult lung recipients at 5 centers in Spain. Data were collected before transplantation and at 7 and 30 days after transplantation. Biomarkers included IgG, IgM, IgA, complement factors C3 and C4, titers of antibodies to pneumococcal polysaccharide antigens (IgG, IgA, IgM) and antibodies to cytomegalovirus (IgG), and serum B-cell activating factor (BAFF) levels. The clinical follow-up period lasted 6 months. Clinical outcomes were bacterial infections requiring intravenous anti-microbial agents, cytomegalovirus (CMV) disease, and fungal infections requiring therapy. We found that 33 patients (40.2%) developed at least 1 serious bacterial infection, 8 patients (9.8%) had CMV disease, and 10 patients (12.2%) had fungal infections. Lower IgM antibody levels against pneumococcal polysaccharide antigens at Day 7 (defined as <5 mg/dl) were a risk factor for serious bacterial infection (adjusted odds ratio [OR] 3.96; 95%confidence interval [CI] 1.39 to 11.26; p = 0.0099). At Day 7 after transplantation, IgG hypogammaglobulinemia (defined as IgG <600 mg/dl) was associated with a higher risk of CMV disease (after adjustment for CMV mismatch: OR 8.15; 95% CI 1.27 to 52.55; p = 0.028) and fungal infection (adjusted OR 8.03, 95% CI 1.51 to 42.72; p = 0.015). Higher BAFF levels before transplantation were associated with a higher rate of development of serious bacterial infection and acute cellular rejection. Early monitoring of specific humoral immunity parameters proved useful for the identification of lung recipients who are at risk of serious infections.

The North Wind and the Sun: Pediatric Antimicrobial Stewardship Program Combining Restrictive and Persuasive Approaches in Hematology-Oncology Ward and Hematopoietic Stem Cell Transplant Unit.

The Japanese government's goal for the reduction of antimicrobial consumption is two-thirds of the 2013 rate by 2020. While the antimicrobial stewardship programs (ASPs) are essential in health care facilities, ASP data on pediatric hematology-oncology and hematopoietic stem cell transplant (HSCT) patients are limited. Our aim was to evaluate the impact of restrictive and persuasive ASP on immunocompromised children. The ASP for hematology-oncology and HSCT patients at Tokyo Metropolitan Children's Medical Center was assessed. Phase 1 was a postprescriptive review of carbapenem conducted between April 2010 and September 2011. Phase 2 consisted of the preauthorization of carbapenem, prospective audit with feedback, a weekly luncheon meeting among physicians, consensus on febrile neutropenia management, and implementation of viral molecular diagnostics between October 2011 and September 2015. Both phases were compared for day-of-therapy per 1,000 patient-days, cost of intravenous antimicrobial agents, average hospitalization duration, all-cause mortality, infection-related mortality at 30 days, and appropriateness of empirical treatment of bacteremia. The ASP did not differ from phase 1 to phase 2 in terms of average hospitalization length, mortality rate, or appropriateness of empirical treatment for bacteremia. Day-of-therapies of cefepime, piperacillin/tazobactam, meropenem, vancomycin, liposomal amphotericin B, and fosfluconazole decreased by 20%, 45%, 57%, 38%, 85% and 44%, respectively (P < 0.05). The total cost of antibiotic and antifungal agents decreased by 27%, for a savings of $59,905 USD annually. Restrictive and persuasive ASP in the hematology-oncology ward and the HSCT unit safely decreased the use of antibacterial and antifungal agents.

Cost minimization analysis on IV to oral conversion of antimicrobial agent by the clinical pharmacist intervention

Antimicrobial agents are used to treat the infectious diseases which and has become a routine milieu. Prescribing intravenous (IV) antimicrobial agents are needed for abruptly subduing the infectious stage and will leads to decrease the infectious severity of the patient. The cost minimization Analysis involved monitoring the IV to oral conversions carried out in General Medicine department as a part of Antimicrobial stewardship Programme (ASP) for initial 3 months followed by feedbacks, guideline preparation and CME programs as intervention. This was followed up by a post-intervention audit to assess the effectiveness of the interventions performed. An aggregate of 102 subjects were enrolled in the study and quantitative use of the parenteral AMA was found to be significantly reduced in the post-interventional phase in comparison to the pre-interventional phase (p=0.028) and the conversion per patient rate is also increased (p=0.0001). Similar reductions were also achieved by the intervention in the duration required for oral conversions, average difference is 2days (p=0.000). 19.5% reduction in the usage of cost of antibiotics is achieved with a 0.010076DDD/100 Bed days difference to the control population. The study was successful in increasing the conversion rate which clearly implicated the acceptance of guideline. The recommendations of the clinical pharmacist were successful in reducing both the length of stay and duration of parenteral therapy, there in reducing the consumption and cost of antimicrobial therapy. The cost minimizations were found by IV to oral conversion of antibiotics without any change in the treatment outcome.

Simultaneous occurrence of hypermucoviscous Klebsiella pneumoniae emphysematous prostatic abscess, emphysematous cystitis, and renal abscess.

Emphysematous prostatic abscess is a rare clinical entity of uncomplicated urinary tract infections with high mortality rate. Here we report a case of hypermucoviscous Klebsiella pneumoniae causing emphysematous prostatic abscess, emphysematous cystitis, and renal abscess simultaneously in a 75-year-old Japanese male with diabetes mellitus and advanced gastric cancer. The patient was successfully treated with prolonged intravenous antimicrobial agents.

Effectiveness of an early switch from intravenous to oral antimicrobial therapy for lower respiratory tract infection in patients with severe motor intellectual disabilities.

An early switch from intravenous to oral antimicrobial therapy is useful for reducing the duration of the hospitalization in adult patients with community acquired-pneumonia, whereas the efficacy of switch therapy for pediatric patients with community acquired (CA)-lower respiratory tract infection (LRTI) is uncertain. The aim of this study is to investigate the efficacy of switch therapy for LRTI in patients with severe motor intellectual disabilities (SMID). This retrospective study was performed on 92 patients with SMID who were admitted to the Department of Pediatrics at the Hospital of University of Occupational and Environmental Health, Japan from April 1, 2010 to March 31, 2017 for the suspicion of bacterial LRTI and were initially treated with an intravenous antimicrobial agent. Clinical outcomes were compared between patients with switch therapy (Switch therapy group) and conventional intravenous antimicrobial therapy (No switch therapy group). Thirteen and 79 in patients with SMID belonged to Switch thrapy group and No switch therapy group, respectively. Length of hospital stay in Switch therapy group was significantly shorter than that in No switch therapy group (P=0.002). In the patients undergoing switch therapy, there was no patient who required re-treatment and/or re-hospitalization. Switch therapy for LRTI was useful for the reduction of length of hospital stay without increasing risk of re-treatment and re-hospitalization in patients with SMID.