Bharath Sunkara

Automated Alerts Coupled with Antimicrobial Stewardship Intervention Lead to Decreases in Length of Stay in Patients with Gram-Negative Bacteremia

OBJECTIVE To assess the impact of active alerting of positive blood culture data coupled with stewardship intervention on time to appropriate therapy, length of stay, and mortality in patients with gram-negative bacteremia. DESIGN Quasi-experimental retrospective cohort study in patients with gram-negative bacteremia at the Detroit Medical Center from 2009 to 2011. SETTING Three hospitals (1 community, 2 academic) with active antimicrobial stewardship programs within the Detroit Medical Center. PATIENTS All patients with monomicrobial gram-negative bacteremia during the study period. INTERVENTION Active alerting of positive blood culture data coupled with stewardship intervention (2010-2011) compared with patients who received no formalized stewardship intervention (2009). RESULTS Active alerting and intervention led to a decreased time to appropriate therapy (8 [interquartile range (IQR), 2-24] vs 14 [IQR, 2-35] hours; P = .014) in patients with gram-negative bacteremia. After controlling for differences between groups, being in the intervention arm was associated with an independent reduction in length of stay (odds ratio [OR], 0.73 [95% confidence interval (CI), 0.62-0.86]), correlating to a median attributable decrease in length of stay of 2.2 days. Additionally, multivariate modeling of patients who were not on appropriate antimicrobial therapy at the time of initial culture positivity showed that patients in the intervention group had a significant reduction in both length of stay (OR, 0.76 [95% CI, 0.66-0.86]) and infection-related mortality (OR, 0.24 [95% CI, 0.08-0.76]). CONCLUSIONS Active alerting coupled with stewardship intervention in patients with gram-negative bacteremia positively impacted time to appropriate therapy, length of stay, and mortality and should be a target of antimicrobial stewardship programs.

Efficacy of Ertapenem for Treatment of Bloodstream Infections Caused by Extended-Spectrum-β-Lactamase-Producing Enterobacteriaceae

ABSTRACT Ertapenem is active against extended-spectrum-β-lactamase (ESBL)-producing Enterobacteriaceae organisms but inactive against Pseudomonas aeruginosa and Acinetobacter baumannii. Due to a lack of therapeutic data for ertapenem in the treatment of ESBL bloodstream infections (BSIs), group 2 carbapenems (e.g., imipenem or meropenem) are often preferred for treatment of ESBL-producing Enterobacteriaceae, although their antipseudomonal activity is unnecessary. From 2005 to 2010, 261 patients with ESBL BSIs were analyzed. Outcomes were equivalent between patients treated with ertapenem and those treated with group 2 carbapenems (mortality rates of 6% and 18%, respectively; P = 0.18).

Comparison of the Clinical Characteristics and Outcomes Associated with Vancomycin-Resistant Enterococcus faecalis and Vancomycin-Resistant E. faecium Bacteremia

ABSTRACT In published studies, cohorts of patients with bacteremia due to vancomycin-resistant Enterococcus (VRE) have predominantly been infected with Enterococcus faecium. Little is known about the epidemiology and outcomes associated with bacteremia due to VR Enterococcus faecalis. A retrospective study of isolates obtained from January 2008 to October 2010 was conducted at Detroit Medical Center (DMC). Unique patients with blood cultures positive for VRE were reviewed. Outcomes were analyzed using logistic regression. During the study period, 105 cases of bacteremia due to VR E. faecalis and 197 cases of bacteremia due to VR E. faecium were identified. The mean age in the study cohort was 61.5 ± 15 years; 162 subjects (53.6%) were male. After controlling for a propensity score, bacteremia due to VR E. faecalis was associated with >2-fold-lower in-hospital mortality than bacteremia due to VR E. faecium. Interestingly, bacteremia due to VR E. faecalis was associated with longer hospital stay after VRE isolation, although total length of stay was similar for groups with VR E. faecalis and VR E. faecium. Bacteremia due to VR E. faecalis was associated with a >2-fold-lower risk for mortality than bacteremia due to VR E. faecium, possibly due to the availability of β-lactam therapeutics for treatment of VR E. faecalis.

Treatment of Methicillin-Resistant Staphylococcus aureus Infections with a Minimal Inhibitory Concentration of 2 μg/mL to Vancomycin: Old (Trimethoprim/Sulfamethoxazole) versus New (Daptomycin or Linezolid) Agents

Background: Guidelines recommend that agents other than vancomycin be considered for some types of infection due to methicillin-resistant Staphylococcus aureus (MRSA) when the minimum inhibitory concentration (MIC) to vancomycin is 2 μg/mL or more. Alternative therapeutic options include daptomycin and linezolid, 2 relatively new and expensive drugs, and trimethoprim/sulfamethoxazole (TMP/SMX), an old and inexpensive agent. Objective: To compare the clinical efficacy and potential cost savings associated with use of TMP/SMX compared to linezolid and daptomycin. Methods: A retrospective study was conducted at Detroit Medical Center. For calendar year 2009, unique adults (age >18 years) with infections due to MRSA with an MIC to vancomycin of 2 μg/mL were included if they received 2 or more doses of TMP/SMX and/or daptomycin and/or linezolid. Data were abstracted from patient charts and pharmacy records. Results: There were 328 patients included in the study cohort: 143 received TMP/SMX alone, 89 received daptomycin alone, 75 received linezolid alone, and 21 patients received a combination of 2 or more of these agents. In univariate analysis, patients who received TMP/SMX alone had significantly better outcomes, including in-hospital (p = 0.003) and 90-day mortality (p < 0.001) compared to patients treated with daptomycin or linezolid. Patients receiving TMP/SMX were also younger (p < 0.001), had fewer comorbid conditions (p < 0.001), had less severe acute severity of illness (p < 0.001), and received appropriate therapy more rapidly (p = 0.001). In multivariate models the association between TMP/SMX treatment and mortality was no longer significant. Antimicrobial cost savings associated with using TMP/SMX averaged

Hospital bath basins are frequently contaminated with multidrug-resistant human pathogens

2067.40 per patient. Conclusions: TMP/SMX monotherapy compared favorably to linezolid and daptomycin in terms of treatment efficacy and mortality. Use of TMP/SMX instead of linezolid or daptomycin could potentially significantly reduce antibiotic costs. TMP/SMX should be considered for the treatment of MRSA infection with MIC of 2 μg/mL to vancomycin.

Extended-Spectrum β-Lactamase Producers Reported as Susceptible to Piperacillin-Tazobactam, Cefepime, and Cefuroxime in the Era of Lowered Breakpoints and No Confirmatory Tests

The hospital environment is increasingly recognized as a reservoir for hospital-acquired pathogens. During a 44-month study period, a total of 1,103 basins from 88 hospitals in the United States and Canada were sampled. Overall, 62.2% of the basins (at least 1 basin at each hospital) were contaminated with commonly encountered hospital-acquired pathogens.

Growing Prevalence of Vancomycin-Resistant Enterococcus faecalis in the Region with the Highest Prevalence of Vancomycin-Resistant Staphylococcus aureus

Cefepime, and Cefuroxime in the Era of Lowered Breakpoints and No Confirmatory Tests Author(s): Dror Marchaim, MD; Bharath Sunkara, MD; Paul R. Lephart, PhD; Uma Mahesh Gudur, MBBS; Ashish Bhargava, MD; Ryan P. Mynatt, PharmD; Jing J. Zhao, PharmD; Suchitha Bheemreddy, MD; Kayoko Hayakawa, MD, PhD; Teena Chopra, MD; Sorabh Dhar, MD; Keith S. Kaye, MD, MPH Source: Infection Control and Hospital Epidemiology, Vol. 33, No. 8 (August 2012), pp. 853-855 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/666632 . Accessed: 26/07/2013 10:59

Fosfomycin activity versus carbapenem-resistant Enterobacteriaceae and vancomycin-resistant Enterococcus , Detroit, 2008–10

Highest Prevalence of Vancomycin-Resistant Staphylococcus aureus • Author(s): Kayoko Hayakawa, MD, PhD; Dror Marchaim, MD; Celine Vidaillac, PharmD, PhD; Paul Lephart, PhD; Jason M. Pogue, PharmD; Bharath Sunkara, MBBS, MPH; Harikrishna Kotra, MBBS; Asma Hasan, BS; Maryann Shango, BS; Yashwanth Yerramalla, MBBS; Adedayo M. Osunlana, MBBS; Teena Chopra, MD; Sorabh Dhar, MD; Hossein Salimnia, PhD; Michael J. Rybak, PharmD, MPH; Keith S. Kaye, MD, MPH Source: Infection Control and Hospital Epidemiology, Vol. 32, No. 9 (September 2011), pp. 922924 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/661599 . Accessed: 17/05/2014 11:39

Predictors and outcomes of linezolid-resistant vancomycin-resistant Enterococcus: A case-case-control study

Fosfomycin activity versus carbapenem-resistant Enterobacteriaceae and vancomycin-resistant Enterococcus , Detroit, 2008–10

Left ventricular pseudoaneurysm as a fatal complication of purulent pericarditis

Linezolid is an important agent for the treatment of infections because of vancomycin-resistant Enterococcus (VRE). This study identified independent predictors for isolation of linezolid-resistant VRE (LZD-R-VRE) and analyzed outcomes associated with linezolid resistance. Immunosuppression, prior surgery, and previous exposure to β-lactam antibiotics were independent predictors for isolation of LZD-R-VRE but not for LZD-susceptible-VRE. Prior exposure to linezolid was not a predictor for isolation of LZD-R-VRE.