Total Duration Of Antimicrobial Therapy Research Articles

Trimethoprim/Sulfamethoxazole vs Minocycline for the Treatment of Nonurinary Monomicrobial Stenotrophomonas maltophilia Infections in Hospitalized Patients.

Stenotrophomonas maltophilia is an opportunistic, gram-negative bacillus with few therapeutic options due to a high level of intrinsic resistance. Trimethoprim/sulfamethoxazole (SXT) is recommended as the first-line treatment; however, minocycline (MIN) has been shown to have similar clinical outcomes in treating S. maltophilia and addresses concern for increasing resistance to SXT. The objective of this study is to evaluate the efficacy and safety outcomes of nonurinary, monomicrobial infections due to S. maltophilia in hospitalized patients treated with MIN or SXT. This was a retrospective study of hospitalized adult patients receiving MIN or SXT for nonurinary monomicrobial S. maltophilia infection from April 1, 2018 to March 31, 2020. The primary outcome was clinical disposition classified as rates of clinical failure, clinical improvement, or clinical success. Eighty-two patients (88.2%) received MIN and 11 patients (11.8%) received SXT initially. Clinical failure occurred in 16 (19.5%) patients in the MIN group and in 4 (36.4%) patients in the SXT group (P = 0.242). Clinical improvement occurred in 11 (13.4%) patients in the MIN group and in 1 (9.1%) patient in the SXT group (P = 1.0). Clinical success occurred in 55 (67.1%) patients in the MIN group and in 6 (54.5%) patients in the SXT group (P = 0.503). Total duration of antimicrobial therapy (P = 0.3198), in-hospital mortality (P = 1.0), hospital length of stay (P = 0.9668), intensive care unit (ICU) length of stay (P = 0.1384), and 30-day readmission (P = 0.686) were similar between groups. Rates of clinical failure, clinical improvement, or clinical success were similar between MIN and SXT for nonurinary monomicrobial S. maltophilia infections.

467. Antifungal Therapy in Candida Intra-abdominal Infections Following Source Control

Abstract Background Current literature suggests that many surgical patients with Candida isolated from an intra-abdominal source do not develop symptomatic infections, however, Infectious Disease Society of America (IDSA) Guidelines recommend antifungal treatment in Candida intra-abdominal infections. An article published by Fabre et al found similar incidence of treatment failure between patients appropriately treated for Enterococcus intra-abdominal infections compared to patients without Enterococcus coverage following source control. Enterococcus and Candida are both low-virulent microorganisms, questioning the necessity of antifungal therapy following source control in Candida intra-abdominal infections. Methods This was a retrospective, cohort study of adult patients with intra-abdominal infections who underwent source control and isolation of Candida in intra-abdominal cultures. Eligible patients were separated based on receipt of antifungals. Patients were excluded if they received between 24 hours and 3 days of antifungal therapy, had candidemia prior to intervention, or received prophylactic or therapeutic antifungals within 7 days of intervention. The antifungal group and non-antifungal group were assessed for incidence of treatment failure, defined as death or additional unplanned surgical or antimicrobial interventions for intra-abdominal infections. Results A total of 125 patients were included with 77 patients (61.6%) receiving antifungal therapy and 48 patients (38.4%) not receiving antifungal therapy. Patients who received antifungal therapy had a higher median SAPS II score (29 vs 22.5; p = 0.003). There was no difference in the incidence of treatment failure at 30 days between the antifungal and non-antifungal groups (41.6% and 35.2%, respectively; p = 0.62). Median hospital length of stay (14 vs 8.5 days; p < 0.001) and median total duration of antimicrobial therapy (10 vs 7 days; p = 0.667) was longer in the antifungal group compared to the non-antifungal group, respectively. Conclusion Patients with Candida intra-abdominal infections that underwent source control had a similar rate of treatment failure at 30 days regardless of receipt of antifungal therapy. However, those who received antifungal therapy had a higher severity of illness. Disclosures Dustin R. Carr, PharmD, BCPS, BCIDP, Merck: Honoraria Derek N. Bremmer, PharmD, BCPS-AQ ID, Thermo Fisher Scientific: Honoraria.

Staphylococcus lugdunensis prosthetic joint infection: A multicentric cohort study

ObjectivesTo describe Staphylococcus lugdunensis prosthetic joint infection (PJI) management and outcome. MethodsAdults with proven S. lugdunensis PJI were included in a multicentric retrospective cohort. Determinants for failure were assessed by logistic regression and treatment failure-free survival curve analysis (Kaplan-Meier). ResultsOne hundred and eleven patients were included (median age 72.4 [IQR, 62.7–79.4] years), with a knee (n = 71, 64.0%) or hip (n = 39, 35.1%) PJI considered as chronic in 77 (69.4%) cases. Surgical management consisted in debridement, antibiotic with implant retention (DAIR; n = 60, 54.1%), two-stage (n = 28, 25.2%) or one-stage (n = 15, 13.5%) exchange. Total duration of antimicrobial therapy was 13.1 (IQR, 11.8–16.9) weeks. After a median follow-up of 99.9 (IQR, 53.9–178.1) weeks, 22 (19.8%) S. lugdunensis-related treatment failures were observed. Independent determinants for outcome were diabetes (OR, 3.741; p = 0.036), sinus tract (OR, 3.846; p = 0.032), DAIR (OR, 3.749; p = 0.039) and rifampin-based regimen (OR, 0.319; p = 0.043). Twenty-four (40.0%) of the 60 DAIR-treated patients experienced treatment failure, with hip location (OR, 3.273; p = 0.048), delay from prosthesis implantation (OR, 1.012 per month; p = 0.019), pre-surgical CRP level >115 mg/L (OR, 4.800; p = 0.039) and mobile component exchange (OR, 0.302; p = 0.069) constituting additional determinants of outcome. ConclusionsStaphylococcus lugdunensis PJI are difficult-to-treat infections, with pivotal roles of an optimal surgical management.

Detecting inappropriate total duration of antimicrobial therapy using semi-automated surveillance

ObjectivesEvaluation of the appropriateness of the duration of antimicrobial treatment is a cornerstone of antibiotic stewardship programs, but it is time-consuming. Furthermore, it is often restricted to antibiotics prescribed during hospital admission. This study aimed to determine whether mandatory prescription-indication registration at the moment of prescribing antibiotics enables reliable automated assessment of the duration of antibiotic therapy, including post-discharge duration, limiting the need for manual chart review to data validation.MethodsAntibiotic prescription and admission data, from 1-6-2020 to 31-12-2021, were electronically extracted from the Electronic Medical Record of two hospitals using mandatory indication registration. All consecutively prescribed antibiotics of adult patients who received empiric therapy in the first 24 h of admission were merged to calculate the total length of therapy (LOT) per patient, broken down per registered indication. Endpoints were the accuracy of the data, evaluated by comparing the extracted LOT and registered indication with the clinical notes in 400 randomly selected records, and guideline adherence of treatment duration. Data were analysed using a reproducible syntax, allowing semi-automated surveillance.ResultsA total of 3,466 antibiotic courses were analysed. LOT was accurately retrieved in 96% of the 400 evaluated antibiotic courses. The registered indication did not match chart review in 17% of antibiotic courses, of which only half affected the assessment of guideline adherence. On average, in 44% of patients treatment was continued post-discharge, accounting for 60% (± 19%) of their total LOT. Guideline adherence ranged from 26 to 75% across indications.ConclusionsMandatory prescription-indication registration data can be used to reliably assess total treatment course duration, including post-discharge antibiotic duration, allowing semi-automated surveillance.

Early antimicrobial stewardship team intervention on appropriateness of antimicrobial therapy in suspected sepsis: a randomized controlled trial.

ObjectivesThere has been concern that the imperative to administer rapid antimicrobials in septic patients may result in inappropriate antimicrobial use. We aimed to determine the impact of early antimicrobial stewardship (AMS) team intervention in patients with Medical Emergency Team (MET) calls for suspected sepsis.MethodsWe performed a randomized controlled trial of non-ICU inpatients who had a MET call for suspected sepsis. Patients were randomized to standard care (management of antimicrobial therapy by the treating team) or early targeted intervention (AMS review 48 h post-MET call). The primary outcome was appropriateness of antimicrobial therapy 72 h post-MET call, as determined by a panel of blinded infectious diseases physicians.ResultsIn total, 90 patients were enrolled; 45 were randomly allocated to the intervention group, and 45 to the control group. More patients in the AMS intervention group were receiving appropriate antimicrobials 72 h following the MET call (67% versus 44%, P = 0.03). In the intervention group, 27 recommendations were made by the AMS team; 74% of recommendations were accepted, including 30% of cases where antimicrobials were discontinued or de-escalated. There were non-significant differences in total duration of antimicrobial therapy (8.7 versus 10.7 days, P = 0.39), sepsis-related ICU-admission rates (13% versus 18%, P = 0.56) and sepsis-related in-hospital mortality (7% versus 9%, P = 0.71) between intervention and control groups, respectively.ConclusionsAMS team intervention resulted in significant improvement in appropriateness of antimicrobial therapy following MET calls due to suspected sepsis. Targeted AMS review should be implemented to support early antimicrobial de-escalation and optimization in patients with suspected sepsis.

64. Impact of a Duration Bundle on Antimicrobial Use in a Pediatric Hospital

BackgroundLimiting antibiotic durations to the shortest effective duration is a strong recommendation with moderate-quality evidence in the 2016 IDSA Antimicrobial Stewardship Program (ASP) guidelines. An ASP bundle including a decrease in antimicrobial automatic stop dates from 14 days to 10 days along with a guideline for standard durations for 48 specific indications was implemented at a tertiary pediatric hospital in November 2019. The purpose of this review and was to assess the impact of this ASP initiative on patient outcomes and hospital cost-savings by comparison of pre-intervention and post-intervention data.MethodsA set of antimicrobial duration recommendations for pediatric patients was created by the Antimicrobial Stewardship Program, Pediatric Hospital Medicine providers, and Infectious Disease providers specific to indication, agent, or pathogen. After education of medical care providers and distribution of the recommendations, automatic stop dates in the Electronic Medical Record (EMR) were updated from 14 days to 10 days for all antimicrobials. Concomitant advertising campaigns were shown on all hospital screensavers. Data were collected for a one month pre-intervention period of Nov.15 - Dec.15, 2018 including 133 patients and a one month intervention period of Nov.15 - Dec.15, 2019 including 125 patients.ResultsThe average length of stay decreased from an average of 8.3 days pre-implementation to 6.7 days (p=0.043) post implementation. The ratio of actual to recommended duration also decreased from 1.56 to 1.30 (p< 0.001) when comparing pre vs. post initiative. Balancing measures did not change for restarting treatment within 48 hours of stopping or readmission within 30 days for the same infection. The decrease in inpatient therapy translated to more than $10,000 per year in direct drug cost.ConclusionThis intervention lead to a significant reduction in average length of stay per admission and significantly reduced the secondary outcomes of the total duration of antimicrobial therapy and the ratio of actual duration compared to recommended duration. This lead to cost savings and decreased inappropriate antibiotic exposure.Disclosures All Authors: No reported disclosures

Evaluation of current practice of antimicrobial use and clinical outcome of patients with pneumonia at a tertiary care hospital in Ethiopia: A prospective observational study.

BackgroundAntimicrobial resistance, which is commonly observed in the management of pneumonia, is a major threat to public health and is driven by inappropriate antimicrobial use. The aim of this study was therefore to assess the current practice of antimicrobial utilization and clinical outcomes in the management of adult pneumonia at Tikur Anbessa Specialized Hospital.MethodA prospective observational study was conducted in the internal medicine wards of Tikur Anbessa Specialized Hospital. The study was conducted from 1 September 2016 to 30 June 2017 and patients aged ≥ 14 years and diagnosed with pneumonia were included. Chart review and self-administered questionnaire were used to collect data regarding pneumonia diagnosis and management as well as clinical outcomes (stable, complications, and in-hospital mortality). Descriptive statistics and binary logistic regressions were performed for data analyses.ResultsOut of 200 enrolled patients, clinical diagnosis was supported by microbiologic testing and imaging in 75 (37.5%) and 122 (61.0%) cases, respectively. The treatment approach in almost all patients (99.5%) was empirical and no de-escalation therapy was made even after acquiring culture results. The total duration of antimicrobial therapy was 12.05±5.09 days and vancomycin was the most commonly prescribed antimicrobial agent (25%), with 70% of the patients receiving this drug empirically. Nearly, 30% of the patients missed their antimicrobial doses during the course of treatment and stock-out (36.7%) was the major reason. Close to 113 (66%) of the treating physicians used reference books to prescribe antimicrobial agents. Patients’ outcomes were found to be stable (66%), in-hospital mortality (18.5%), and ending up in complications (17%). Poor clinical outcome (death and complicated cases) was found to be associated with recent antimicrobial use history (p = 0.007, AOR 2.86(1.33–6.13)), cancer (p = 0.023, AOR 3.46(1.18–10.13)), recent recurrent upper respiratory tract infection (p = 0.046, AOR 3.70(1.02–13.40)), respiratory rate >24 breaths/min or <12 breaths/min (p = 0.013, AOR 2.45(1.21–4.95)) and high level of serum creatinine after initiation of antimicrobial therapy (>1.4mg/dl) (p = 0.032, AOR 2.37(1.07–5.20)).ConclusionAntimicrobials are empirically prescribed without sufficient evidence of indication and microbiological or radiological findings. The practice also is not based on local guidelines and no multidisciplinary approach is apparent. [How about: “It is likely that these factors contributed to higher rates of mortality (18.5%) when compared with similar studies in other countries” instead of this “As a result, there were higher rates of mortality (18.5%) when compared with other similar studies”]. Hence, the hospital requires a coordinated intervention to improve rational use of antimicrobials and clinical outcomes through establishing an antimicrobial stewardship program.

Contemporary Microbiology and Antimicrobial Treatment of Complicated Appendicitis: The Value of a Short-term Study.

Antimicrobial stewardship interventions to curtail the use of third-generation cephalosporins and antipseudomonal penicillins for the treatment of complicated appendicitis in children are challenging given the tendency to treat complicated disease with broad-spectrum antimicrobials. Reasons for this are unclear, but there is a paucity of contemporary microbiologic data associated with the child presenting with either acute perforated or gangrenous appendicitis. This study aimed to justify the appropriateness of an empiric regimen consisting of ampicillin, tobramycin/gentamicin plus metronidazole and to analyze duration of postoperative therapy. We conducted a retrospective cohort study from February 1, 2017, to October 31, 2018, in children who underwent appendectomy or interventional radiologic drainage for primary complicated appendicitis. The primary outcome was the proportion of patients who had a pathogen isolated from peritoneal fluid culture that was not susceptible to the recommended empiric therapy. The secondary outcomes were the total duration of antimicrobial therapy and the proportion of patients with a postoperative infectious complication within 30 days after intervention. Of 425 children with primary acute appendicitis, 158 (37%) had complicated appendicitis at presentation. Culture was performed in 53 (40%) of the 133 who underwent a surgical or interventional radiologic intervention. The group with peritoneal cultures was more likely to present with longer symptom duration before admission [3 (interquartile range, 2-5) vs 2 (interquartile range, 1-2) days; P < 0.001] and with purulent peritonitis [47% (25/53) vs 13% (10/80); P < 0.001]. The most common pathogens isolated were anaerobes (81%), Escherichia coli (74%) and Streptococcus anginosus group (62%). Only 4% of isolated bacteria were resistant to empiric therapy. Postoperative infectious complications were documented in 23 (17%) patients and were not associated with the presence of a resistant pathogen or the choice of antimicrobial agents but with more severe disease and higher C-reactive protein values (303 vs 83 mg/L; P=0.03) at presentation. In a cohort of previously healthy children presenting with complicated appendicitis requiring surgical drainage, the most common bacteria from peritoneal cultures continue to be S. anginosus, aminoglycoside-susceptible Gram-negative bacilli and anaerobes. In an attempt to reduce extended-spectrum cephalosporin use, these data were useful in supporting the use of metronidazole with ampicillin and an aminoglycoside, rather than third-generation cephalosporins.

1400. Impact of a Multiplex Polymerase Chain Reaction Meningitis/Encephalitis Panel and Antimicrobial Stewardship Bundle on Antimicrobial Use in Patients with Suspected Meningitis or Encephalitis

BackgroundOptimal treatment of meningitis relies on prompt diagnostic evaluation and initiation of appropriate antimicrobials. The meningitis/encephalitis panel (MEP) is a multiplex rapid polymerase chain reaction, with the ability to detect 14 community-acquired pathogens in 1 hour. The purpose of this study was to evaluate impact of the MEP on de-escalation of antimicrobials in adult inpatients with suspected meningitis at a large community teaching hospital.MethodsThis single-center retrospective quasi-experimental pre/post study included adults admitted for ≥48 hours and initiated on antimicrobial therapy for suspected meningitis. Those with healthcare-associated meningitis, immunosuppression, initiation of antimicrobials >8 hours prior to lumbar puncture (LP), and use of antimicrobials for another indication were excluded. The pre-group included patients admitted prior to MEP introduction. The post-group included patients with the MEP performed. An antimicrobial stewardship bundle consisting of a meningitis order set, provider education, and use of a real-time meningitis alert in clinical decision support software was also implemented in the post-group. The primary outcome was percentage of patients experiencing antimicrobial de-escalation ≤48 hours after LP. Secondary outcomes included time to de-escalation, total duration of antimicrobial therapy (DOT), and hospital length of stay (LOS).ResultsA total of 45 patients were included in the study (23 pre-group and 22 post-group). Baseline characteristics were similar between groups. The percentage of patients experiencing de-escalation of antimicrobials ≤ 48 hours after LP increased by 44% in the post-group (82% vs. 38%, P = 0.005). The overall median time to de-escalation of antimicrobials decreased by 35 hours [11.1 (IQR 5.6, 17.6) vs. 46.1 (IQR 18.4, 66.5); P = 0.002] and the median time to de-escalation after LP decreased by 38 hours [13.6 (IQR 8.3, 20.3) vs. 51.6 (IQR 44.2, 69.8); P < 0.001]. No statistically significant difference in hospital LOS or total DOT was seen.ConclusionImplementation of the MEP and antimicrobial stewardship bundle increased the percentage of patients de-escalated in 48 hours and decreased the time to de-escalation. However, this did not impact the total DOT or hospital LOS.Disclosures All authors: No reported disclosures.

Total duration of antimicrobial therapy resulting from inpatient hospitalization.

To assess the feasibility of electronic data capture of postdischarge durations and evaluate total durations of antimicrobial exposure related to inpatient hospital stays. Multicenter, retrospective cohort study. Two community hospitals and 1 academic medical center. Hospitalized patients who received ≥1 dose of a systemic antimicrobial agent. We collected and reviewed electronic data on inpatient and discharge antimicrobial prescribing from April to September 2016 in 3 pilot hospitals. Inpatient antimicrobial use was obtained from electronic medication administration records. Postdischarge antimicrobial use was calculated from electronic discharge prescriptions. We completed a manual validation to evaluate the ability of electronic prescriptions to capture intended postdischarge antibiotics. Inpatient, postdischarge, and total lengths of therapy (LOT) per admission were calculated to assess durations of antimicrobial therapy attributed to hospitalization. A total of 45,693 inpatient admissions were evaluated. Antimicrobials were given during 23,447 admissions (51%), and electronic discharge prescriptions were captured in 7,442 admissions (16%). Manual validation revealed incomplete data capture in scenarios in which prescribers avoided the electronic system. The postdischarge LOT among admissions with discharge antimicrobials was median 8 days (range, 1-360) with peaks at 5, 7, 10, and 14 days. Postdischarge days accounted for 38% of antimicrobial exposure days. Discharge antimicrobial therapy accounted for a large portion of antimicrobial exposure related to inpatient hospital stays. Discharge prescription data can feasibly be captured through electronic prescribing records and may aid in designing stewardship interventions at transitions of care.

Effect of Clinically Uninfected Orthopedic Implants and Pacemakers/AICDs in Low-Risk Staphylococcus aureus Bloodstream Infection on Crude Mortality Rate: A Post Hoc Analysis of a Large Cohort Study.

BackgroundThe standard treatment duration in low-risk Staphylococcus aureus bloodstream (SAB) is 14 days. However, it is unclear whether an extended course of antimicrobial therapy is necessary in patients with clinically uninfected prosthetic joints/osteosyntheses or pacemakers/automated implanted cardioverter-defibrillators (AICDs). Thus, we compared the duration of antimicrobial therapy and outcomes in patients with and those without clinically uninfected foreign bodies.MethodsWe conducted a post hoc analysis of data from the prospective Invasive Staphylococcus aureus Infection Cohort (INSTINCT) study. Adult low-risk patients who survived ≥4 days were assessed for duration of treatment, SAB-related events (attributable death, relapse, or new deep-seated infection), and survival.ResultsOf the 1288 patients enrolled, 292 satisfied criteria for low-risk SAB. Forty-three patients (15%) had a clinically uninfected pacemaker/AICD or orthopedic implant. Patients with foreign bodies were significantly older (mean age, 72 vs 62 years for those without; P < .001; P = .9) and had a higher Charlson score (median, 3 vs 2; P = .06). The total duration of antimicrobial therapy (median, 18 vs 17 days, respectively; P = .7), all-cause mortality rate (16% vs 14%; P = .7), and prevalence of SAB-related events within 90 days were similar (2% vs 2%) in the 2 groups. At 1-year follow-up, SAB-related events were more frequent in patients with foreign bodies (7% vs 4% in those without; P = .4) (hazard ratio, 1.41; 95% confidence interval, .35–5.69; in a multivariable Cox model), but this difference was not statistically significant.ConclusionsLow-risk patients with clinically uninfected foreign bodies received a similar duration of antimicrobial therapy without a significant impact on mortality rate. The observed higher hazard ratio of SAB-related events within 1 year necessitates additional studies before recommendations concerning treatment duration in this patient subgroup can be adapted or modified.

Measuring Provider Compliance with an Institution-Based Clinical Pathway for Diverticulitis Using Radiologic Criteria.

Diverticulitis remains a common disease encountered in the acute care setting. Management strategies have been developed to guide treatment decisions based on imaging. By using a multi-faceted clinical pathway approach, a standardized method of diagnosing and categorizing disease severity can be performed in order to guide appropriate management. This study evaluated provider compliance with an institutional clinical pathway designed to guide management of diverticulitis. An institutional clinical pathway was developed to manage diverticulitis, including radiologic classification, primary service line assignment, interventional strategies, and antimicrobial treatment. To assess provider compliance with the algorithm, we queried the institutional acute diverticulitis database for patients admitted from May 19, 2016 to February 8, 2017, which identified 83 patients. Provider compliance with the pathway was assessed using subgroup analysis of radiologic documentation (modified Neff [mNeff] classification), primary service assignment, and interventions (i.e., interventional radiology [IR] and antimicrobial agents). The cohort represented a diverse group of mNeff classifications, predominantly Stage 0. Surgical interventions occurred in 10.8% of the cohort. Antimicrobial agents were administered to 88.0% and 78.3% of the outpatients and inpatients, respectively. Patients received a total duration of antimicrobial therapy (mean ± standard deviation [SD]) of 10.2 ± 5.1 days. Overall compliance occurred in 10% of the patients. Compliance with radiologic documentation, antimicrobial choice, and antimicrobial duration were 90.4%, 20.5%, and 69.9%, respectively. Overall compliance with the clinical pathway was poor, except as it related to compliance with radiologic documentation, appropriate assignment to surgical service line, and antimicrobial duration. These results suggest areas for future improvement to augment compliance with the clinical pathway.

Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: Results of a national medication utilization evaluation

Practice guidelines recommend the shortest duration of antimicrobial therapy appropriate to treat uncomplicated pneumonia be prescribed to reduce the emergence of resistant pathogens. A national evaluation was conducted to assess the duration of therapy for pneumonia. Retrospective medication utilization evaluation. Thirty Veterans Affairs medical centers. Inpatients discharged with a diagnosis of pneumonia. A manual review of electronic medical records of inpatients discharged with uncomplicated community-acquired pneumonia (CAP) or healthcare-associated pneumonia (HCAP) was conducted. Appropriate CAP therapy duration was defined as at least 5 days, and up to 3 additional days beginning the first day the patient achieved clinical stability criteria; the appropriate HCAP therapy duration was defined as 8 days. The duration of antimicrobial therapy for intravenous (IV) and oral (PO) inpatient administration, PO therapy dispensed upon discharge, Clostridium difficile infection (CDI), hospital readmission, and death rates were measured. Of 3881 pneumonia admissions, 1739 met inclusion criteria (CAP [n = 1195]; HCAP [n = 544]). Overall, 13.9% of patients (CAP [6.9%], HCAP [29.0%]) received therapy duration consistent with guideline recommendations. The median (interquartile range) days of therapy were 4 days (3-6 days), 1 day (0-3 days), and 6 days (4-8 days) for inpatient IV, inpatient PO, and outpatient PO antimicrobials, respectively. CDI was rare but more common in patients who received therapy duration consistent with guidelines. Therapy duration was not associated with the readmission or mortality rate. Antimicrobials were commonly prescribed for a longer duration than guidelines recommend. The majority of excessive therapy was completed upon discharge, identifying the need for strategies to curtail unnecessary use postdischarge. Journal of Hospital Medicine 2015;11:832-839. © 2015 Society of Hospital Medicine.

Suggestions for managing pyogenic (non-tuberculous) discitis in adults

Objectives To develop recommendations about identifying the causative organism, obtaining imaging studies, and selecting pharmacological and non-pharmacological treatments in adults with pyogenic discitis and vertebral osteomyelitis (PDVO). Methods A rheumatologist and an infectiologist drafted recommendations based on their personal experience and a review of studies in English or French retrieved on Medline using the following search terms: “infectious spondylodiscitis”, “infectious spondylitis”, “spondylodiscitis”, “discitis”, “vertebral osteomyelitis”, “spine infection”, and “bone and joint infections”. The recommendations were submitted to four experts for validation. Results 85 articles were selected for detailed review. No prospective randomized controlled trials were identified. Antimicrobial therapy should be initiated only after recovery of the causative organism in blood cultures or percutaneous disk biopsy specimens, except in patients with neutropenia or severe sepsis. The initial treatment rests on a combination of two bactericidal and synergistic antimicrobials in high dosages. The total duration of antimicrobial therapy should be 12 weeks at least. Radiographs of the spine and chest and magnetic resonance imaging (MRI) of the spine should be performed routinely during the initial evaluation. In PDVO due to hematogenous dissemination of a streptococcus or staphylococcus, routine echocardiography may be in order. Radiographs centered on the affected disk should be obtained 1 and 3 months into antimicrobial therapy and 3 months after treatment discontinuation. Follow-up MRI is usually unnecessary when the clinical and laboratory abnormalities respond to treatment. If not, or if the initial investigations show a collected abscess, a repeat MRI after 1 month of antimicrobial treatment may be useful. Clinical and laboratory follow-up is mandatory throughout antimicrobial therapy and during the first 6 months after treatment discontinuation. Conclusions Recommendations based on descriptive studies and expert opinion were developed. They can be expected to improve the quality and uniformity of PDVO management. Further studies are needed to improve the level of evidence that is available for developing recommendations. In particular, prospective randomized multicenter studies should be performed to compare the intravenous to the oral route for initial antimicrobials administration and to compare different treatment durations.

Intravenous followed by oral antimicrobial therapy for staphylococcal endocarditis.

We have treated 35 cases of staphylococcal endocarditis in 33 patients with intravenous followed by oral antimicrobial therapy. All patients had three or more blood cultures positive for Staphylococcus aureus, and all had cardiac murmurs characteristic of valvular insufficiency. The mean total duration of antimicrobial therapy was 42.4 d, consisting of a mean of 16.4 d of intravenous therapy followed by a mean of 26 d of oral therapy. Intravenous antimicrobial therapy included sodium nafcillin (32 cases; mean dose 9.2 g daily) and clindamycin (three cases). Oral therapy included dicloxacillin or oxacillin (30 cases; mean dose 4.5 g daily), clindamycin (four cases), and potassium penicillin V (one case). Serum bactericidal titers using the blood culture isolates showed similar activity with both intravenous and oral drugs. All patients treated with this sequential intravenous and oral regimen were cured. A regimen of initial intravenous followed by oral antimicrobial therapy, monitored with serum antibacterial activity studies, is a safe, effective, well-tolerated, and economical treatment for staphylococcal endocarditis.