Chris A. Gentry

Outcomes of Health Care–Associated Pneumonia Empirically Treated with Guideline-Concordant Regimens Versus Community-Acquired Pneumonia Guideline–Concordant Regimens for Patients Admitted to Acute Care Wards from Home

BACKGROUND The introduction of the health care–associated pneumonia (HCAP) categorization expanded recommendations for broad-spectrum empiric antibiotics to pneumonia patients presenting from the community with recent health care–system exposure. However, the efficacy of such regimens in improving clinical outcomes in these patients has not been well established. OBJECTIVE To compare the clinical outcomes of HCAP patients treated initially with HCAP guideline–concordant antibiotic regimens to those treated initially with community-acquired pneumonia (CAP) guideline-concordant antibiotic regimens. METHODS This retrospective study included HCAP patients presenting from home and admitted to general medical wards. HCAP regimen patients were treated empirically with at least 1 antipseudomonal agent. All other patients were assigned to the CAP regimen group. The primary end point was clinical cure at 30 days postdischarge. Subgroup analysis was performed in patients hospitalized 1–30 days and 31–90 days before the HCAP admission. RESULTS Of 228 HCAP admissions, 122 patients received CAP regimens and 106 received HCAP regimens. The 2 groups were similar at baseline, including Pneumonia Severity Index scores. Attributable clinical cure occurred in 75.4% of CAP regimen patients and 69.8% of HCAP regimen patients (p = 0.34). Overall clinical cure occurred in 59.8% of CAP regimen patients and 54.7% of HCAP regimen patients (p = 0.44). The CAP regimen group used fewer days of intravenous antibiotics (4.39 vs 7.75, p < 0.0001) and had shorter lengths of stay (6.36 vs 8.58 days, p < 0.0001). For patients hospitalized 31–90 days earlier, clinical cure was higher in the CAP regimen group (attributable, 82.9% vs 60.0%, p = 0.0090; overall, 67.1% vs 47.5%, p = 0.044). CONCLUSIONS Compared to CAP guideline–concordant regimens, treatment of HCAP with HCAP guideline–concordant regimens did not increase clinical cure rates and was associated with lower clinical cure rates in patients hospitalized 31–90 days prior to the HCAP admission. This study suggests that broad-spectrum empiric antibiotics may not be necessary in all HCAP patient groups.

A Propensity-Matched Analysis Between Standard Versus Tapered Oral Vancomycin Courses for the Management of Recurrent Clostridium difficile Infection

Abstract Background This study was conducted to compare clinical outcomes of oral vancomycin courses without taper versus oral vancomycin courses with taper for treatment of recurrent Clostridium difficile infection (CDI). Methods This investigation was a multicenter, retrospective, propensity score-matched analysis study using a Veterans Health Administration national clinical administrative database. Adult patients who were treated for recurrent CDI from any Veterans Affairs Medical Center between June 1, 2011 and October 31, 2016 were included if they were treated with oral vancomycin with or without a tapering regimen. The 2 groups were matched by next-nearest approach from a propensity score formula derived from independent variables associated with the selection of a taper regimen. Results Propensity score matching resulted in 2 well-matched groups consisting of 226 episodes of patients treated with a vancomycin taper regimen and 678 episodes treated by vancomycin regimen without taper. No difference was found for the primary outcome of 180-day recurrence (59 of 226 [26.1%] for taper regimens versus 161 of 678 [23.8%], P = .48). A secondary outcome of 90-day all-cause mortality met statistical significance, favoring a taper regimen (5.31% vs 9.29%, P = .049); however, secondary outcomes of 90-day recurrence and 180-day all-cause mortality were not different. Conclusions Vancomycin taper regimens did not provide benefit over vancomycin regimens without taper in preventing additional CDI recurrence in patients with first or second recurrent episodes in this propensity score-matched analysis.

A propensity score-matched analysis of the impact of minimum inhibitory concentration on mortality in patients with Pseudomonas aeruginosa bacteraemia treated with piperacillin/tazobactam

The Clinical and Laboratory Standards Institute (CLSI) recently re-examined Pseudomonas aeruginosa minimum inhibitory concentration (MIC) susceptibility breakpoints for piperacillin/tazobactam (TZP). The objectives of this study were to analyse the impact of elevated TZP MICs (32-64 mg/L) versus lower respective MICs on P. aeruginosa bacteraemia patient outcomes. Data were gathered from a Veterans Health Administration national clinical database on P. aeruginosa bacteraemia episodes from 2007 to 2013. Patients treated with TZP were identified, comprising 53 elevated MIC episodes and 301 low MIC episodes. Propensity score matching (1:2 ratio) utilising independent variables associated with 30-day all-cause mortality was conducted to compare the outcomes of 53 elevated MIC episodes with 106 matched low MIC episodes. Independent baseline variables associated with 30-day all-cause mortality for all 354 episodes were hyperkalaemia, elevated blood urea nitrogen, elevated temperature, hypoglycaemia, lack of urinary source and thrombocytopenia. Similar 30-day all-cause mortality was found between the two propensity-matched TZP groups (elevated MIC 24.5% vs. low MIC 22.6%; P = 0.79).

A Prospective Observational Study of Risk Factors for Candida glabrata in an SICU: Role of Fluconazole

Background Candida glabrata has emerged as a serious nosocomial pathogen, particularly in surgical intensive care units (SICU). Purpose To determine potential risk factors for the emergence of C. glabrata colonization or infection (C/I) in the SICU. Methods A prospective observational study was conducted collecting and analyzing variables associated with the development of C/I with C. glabrata versus non-glabrata Candida species in our SICU. Results Fourteen patients developed C/I with C. glabrata (cases), while 21 patients developed C/I with non-glabrata Candida species (controls). Univariate analyses identified the following continuous variables as being statistically significant for the development of C/I with C. glabrata: number of days prior to antifungal or penicillin class therapy. The following categorical variables were significant by univariate analyses: any prior use of piperacillin/tazobactam, penicillin class, or fluconazole, or at least 5 days of use of fluconazole. Any prior use of levofloxacin was found to be statistically significant for controls. Multivariate-logistic regression analysis identified more than 5 days of fluconazole use and no prior use of levofloxacin as independent risk factors for the development of C. glabrata C/I in the SICU. Conclusions Prior fluconazole use was identified as an independent risk factor for development of C. glabrata C/I.

Clinical outcomes of fidaxomicin vs oral vancomycin in recurrent Clostridium difficile infection: XXXX

Recurrent Clostridium difficile infection (CDI) occurs after initial treatment in approximately 20%‐30% of patients, regardless of therapy chosen. The objective of this study was to assess clinical outcomes of recurrent CDI treated with fidaxomicin or oral vancomycin.

Evaluation of fidaxomicin usage patterns and outcomes for Clostridium difficile infection across the United States Veterans Health Administration

Fidaxomicin was recently approved for the treatment of Clostridium difficile infection (CDI). Limited data on its use exist outside of the phase 3 trials. The purposes of this study were to assess the compliance with the Veterans Health Administration (VHA) fidaxomicin criteria for use and describe patient characteristics and outcomes following fidaxomicin treatment for CDI using real‐world data within the VHA system.

A propensity score-matched analysis of the impact of minimum inhibitory concentration on mortality in patients with Pseudomonas aeruginosa bacteremia treated with cefepime or ceftazidime

The United States Clinical and Laboratory Standards Institute recently elected not to revise ceftazidime and cefepime Pseudomonas aeruginosa minimum inhibitory concentration (MIC) susceptibility breakpoints but rather recommended specific dosage regimens to correspond to breakpoints. This studys objective was to examine mortality of low and high MIC P. aeruginosa isolates in bacteremic patients treated with cefepime or ceftazidime. Data were gathered through a Veterans Health Administration national administrative database for veterans with P. aeruginosa blood cultures who received cefepime or ceftazidime. Seventy-four patients in the low MIC (≤2 μg/mL) group and 29 patients in the high (4-8 μg/mL) MIC group were included. Independent baseline variables associated with 30-day all-cause mortality were determined through multivariate analysis to calculate propensity scores and perform matching. All-cause 30-day mortality was not statistically significant between the 2 resultant propensity score-matched groups (17.2% mortality in the low MIC group versus 27.6% in the high MIC group; P=0.34). Data suggested that P. aeruginosa bacteremia episodes where the cephalosporin MIC = 8 μg/mL may have higher mortality, however this may be reflective of higher propensity scores. Our study suggests that it is reasonable to designate a cefepime or ceftazidime MIC ≤8 μg/mL as susceptible for P. aeruginosa bacteremia infections, but potential suboptimal outcomes in episodes for which the P. aeruginosa MIC is 8 μg/mL may need further investigation.