Christina Sarubbi

Influence of Reported Penicillin Allergy on Mortality in MSSA Bacteremia.

Abstract Background Penicillin allergy frequently impacts antibiotic choice. As beta-lactams are superior to vancomycin in treating methicillin-susceptible Staphylococcus aureus (MSSA) bacteremia, we examined the effect of reported penicillin allergy on clinical outcomes in patients with MSSA bacteremia. Methods In this retrospective cohort study of adults with MSSA bacteremia admitted to a large tertiary care hospital, outcomes were examined according to reported penicillin allergy. Primary outcomes included 30-day and 90-day mortality rates. Multivariable regression models were developed to quantify the effect of reported penicillin allergy on mortality while adjusting for potential confounders. Results From 2010 to 2015, 318 patients with MSSA bacteremia were identified. Reported penicillin allergy had no significant effect on adjusted 30-day mortality (odds ratio [OR], 0.73; 95% confidence interval [CI], 0.29–1.84; P = .51). Patients with reported penicillin allergy were more likely to receive vancomycin (38% vs 11%, P < .01), but a large number received cefazolin regardless of reported allergy (29 of 66, 44%). Mortality rates were highest among nonallergic patients receiving vancomycin (22.6% vs 7.4% for those receiving beta-lactams regardless of reported allergy, P < .01). In multivariable analysis, beta-lactam receipt was most strongly associated with survival (OR, 0.26; 95% CI, 0.12–0.54). Conclusions Reported penicillin allergy had no significant effect on 30- or 90-day mortality. Non-penicillin-allergic patients receiving vancomycin for treatment of MSSA bacteremia had the highest mortality rates overall. Receipt of a beta-lactam was the strongest predictor of survival. These results underscore the importance of correct classification of patients with penicillin allergy and appropriate treatment with a beta-lactam when tolerated.

Effectiveness of Vancomycin or Beta-Lactam Therapy in Ampicillin-Susceptible Enterococcus spp. Bloodstream Infections

Background: De-escalation to a beta-lactam improves outcomes for patients with a methicillin-susceptible Staphylococcus aureus bloodstream infection (BSI). Whether a similar strategy is appropriate for enterococcal species is less clear. Objective: To determine whether definitive antibiotic selection affects outcomes for patients with an ampicillin-susceptible enterococcal BSI. Methods: This retrospective cohort study included patients over 18 years of age receiving definitive therapy with vancomycin or a beta-lactam for one or more blood cultures positive for Enterococcus spp. isolates between 2007 and 2014. Survival differences were examined using a Kaplan-Meier curve with log-rank test. Results: One-hundred eighty-six patients received definitive therapy with either vancomycin (n = 45, 24.2%) or a beta-lactam (n = 141, 75.8%). The primary outcome, 30-day all-cause mortality, was not different between groups (6.7% vs 7.1%; P = .992). A post hoc analysis of all-cause mortality 1 year after the index BSI was significantly higher in the vancomycin group (51% vs 33%; P = .032). In a Cox proportional hazards regression model, definitive vancomycin was associated with an increased risk of all-cause mortality at 1 year (hazard ratio [HR]: 2.39; 95% confidence interval [CI]: 1.41-4.04). Conclusion: For patients with an ampicillin-susceptible enterococcal BSI, definitive therapy with vancomycin or a beta-lactam was not independently associated with a difference in 30-day all-cause mortality. Whether definitive vancomycin is associated with poor long-term outcomes warrants further exploration.

Impact of automatic infectious diseases consultation on the management of fungemia at a large academic medical center

Purpose. The impact of automatic infectious diseases (ID) consultation for inpatients with fungemia at a large academic medical center was studied. Methods. In this single‐center, retrospective study, the time to appropriate antifungal therapy before and after implementing a policy requiring automatic ID consultation for the management of fungemia for all patients with an inpatient positive blood culture for fungus was examined. The rates of ID consultation; the likelihood of receiving appropriate antifungal therapy; central venous catheter (CVC) removal rates; performance of ophthalmologic examinations; infection‐related length of stay (LOS); rates of all‐cause inhospital mortality, death, or transfer to an intensive care unit within 7 days of first culture; and inpatient cost of antifungals were also evaluated. Results. A total of 173 unique episodes (94 and 79 in the control and intervention groups, respectively) were included. Candida species were the most frequently cultured organisms, isolated from over 90% of patients in both groups. No differences were observed between the control and intervention groups in time to appropriate therapy, infection‐related LOS, or time to CVC removal. However, patients in the intervention group were more likely than those in the control group to receive appropriate antifungal therapy (p = 0.0392), undergo ophthalmologic examination (p = 0.003), have their CVC removed (p = 0.0038), and receive ID consultation (p = 0.0123). Inpatient antifungal costs were significantly higher in the intervention group (p = 0.0177). Conclusion. While automatic ID consultation for inpatients with fungemia did not affect the time to administration of appropriate therapy, improvement was observed for several process indicators, including rates of appropriate antifungal therapy selection, time to removal of CVCs, and performance of ophthalmologic examinations.