Dawd S. Siraj

The impact of penicillin skin testing on clinical practice and antimicrobial stewardship

BACKGROUND Penicillin skin testing (PST) is a simple and reliable way of diagnosing penicillin allergy. After being off the market for 4 years, penicilloyl-polylysine was reintroduced in 2009 as PRE-PEN. We describe the negative predictive value (NPV) of PST and the impact on antibiotic selection in a sample of hospitalized patients with a reported history of penicillin allergy. METHODS We introduced a quality improvement process at our 861-bed tertiary care hospital that used PST to guide antibiotic usage in patients with a history consistent with an immunoglobulin E (IgE)-mediated reaction to penicillin. Subjects with a negative PST were then transitioned to a β-lactam agent for the remainder of their therapy. NPV of skin testing was established at 24-hour follow-up. We are reporting the result of 146 patients tested between March 2012 and July 2012. RESULTS A total of 146 patients with a history of penicillin allergy and negative PST were treated with β-lactam antibiotics. Of these, only 1 subject experienced an allergic reaction to the PST. The remaining 145 patients tolerated a full course of β-lactam therapy without an allergic response, giving the PST a 100% NPV. We estimated that PST-guided antibiotic alteration for these patients resulted in an estimated annual savings of

Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome.

82,000. CONCLUSION Patients with a history of penicillin allergy who have a negative PST result are at a low risk of developing an immediate-type hypersensitivity reaction to β-lactam antibiotics. The increased use of PST may help improve antibiotic stewardship in the hospital setting.

Raltegravir: first in class HIV integrase inhibitor

Objective:Antimicrobial stewardship programs have been shown to help reduce the use of unnecessary antimicrobial agents in the hospital setting. To date, there has been very little data focusing on high-use areas, such as the medical ICU. A prospective intervention was done to assess guideline compliance, antimicrobial expenditure, and healthcare cost when an infectious disease fellow interacts regularly with the medical ICU team. Design:A 3-month retrospective chart review was followed by a 3-month prospective intervention the following year. Two hundred forty-six total charts were reviewed to assess generally accepted guideline compliance, demographics, and microbiologic results. Setting:Twenty-four-bed medical ICU at an 861-bed tertiary care, university teaching hospital in North Carolina. Subjects:Patients receiving antibiotics in the medical ICU. Intervention:During the intervention period, the infectious disease fellow reviewed the charts, including physician notes and microbiology data, and discussed antimicrobial use with the medical ICU team. Measurements and Main Results:Antimicrobial use, treatment duration, Acute Physiology and Chronic Health Evaluation II scores, length of stay, mechanical ventilation days, and mortality rates were compared during the two periods. Results:No baseline statistically significant differences in the two groups were noted (i.e., age, gender, race, or Acute Physiology and Chronic Healthcare Evaluation II scores). Indications for antibiotics included healthcare-associated (53%) and community-acquired pneumonias (17%). Significant reductions were seen in extended-spectrum penicillins (p = 0.0080), carbapenems (p = 0.0013), vancomycin (p = 0.0040), and metronidazole (p = 0.0004) following the intervention. Antimicrobial modification led to an increase in narrow-spectrum penicillins (p = 0.0322). The intervention group had a significantly lower rate of treatments that did not correspond to guidelines (p < 0.0001). There was a reduction in mechanical ventilation days (p = 0.0053), length of stay (p = 0.0188), and hospital mortality (p = 0.0367). The annual calculated healthcare savings was

Osteomyelitis Infection of Mycobacterium marinum: A Case Report and Literature Review.

89,944 in early antibiotic cessation alone. Conclusion:Active communication with an infectious disease practitioner can significantly reduce medical ICU antibiotic overuse by earlier modification or cessation of antibiotics without increasing mortality. This in turn can reduce healthcare costs, foster prodigious education, and strengthen relations between the subspecialties.

Medical care of pregnant women in eastern North Carolina with human immunodeficiency virus.

On October 16, 2007, the US Food and Drug Administration (FDA) approved raltegravir for treatment of human immunodeficiency virus (HIV)-1 infection in combination with other antiretroviral agents in treatment-experienced adult patients who have evidence of viral replication and HIV-1 strains resistant to multiple antiretroviral agents. Raltegravir is first in a novel class of antiretroviral drugs known as integrase inhibitors. It has demonstrated potent anti HIV activity in both antiretroviral treatment-naïve and experienced patients. The most common adverse events reported with raltegravir during phase 2 and 3 clinical trials were diarrhea, nausea, and headache. Laboratory abnormalities include mild elevations in liver transaminases and creatine phosphokinase.

Use of Voriconazole for the Treatment of Paecilomyces lilacinus Cutaneous Infections: Case Presentation and Review of Published Literature

Mycobacterium marinum (M. marinum) is a ubiquitous waterborne organism that grows optimally at temperatures around 30°C. It is a nontuberculous Mycobacterium found in nonchlorinated water with worldwide prevalence. It is the most common atypical Mycobacterium that causes opportunistic infection in humans. M. marinum can cause superficial infections and localized invasive infections in humans, with the hands being the sites most frequently affected. It can cause skin lesions, which are either single, papulonodular lesions, confined to an extremity, or may resemble cutaneous sporotrichosis. This infection can also cause deeper infections including tenosynovitis, bursitis, arthritis, and osteomyelitis. Disseminated infections and visceral involvements have been reported in immunocompromised patients. We here report a case of severe deep soft tissue infection with necrotizing fasciitis and osteomyelitis of the left upper extremity (LUE) caused by M. marinum in an immunocompromised patient.

Nodular Skin Lesion in a Returning Traveler

Objectives To assess the time lag between the diagnosis of human immunodeficiency virus (HIV) and the initiation of antiretroviral therapy (ART) in pregnant women. Methods A retrospective chart review of 105 deliveries from HIV-positive women from January 2001 to June 2009 was undertaken. Results One hundred five HIV-infected pregnant women were identified and studied. Forty-eight women were diagnosed during the prenatal visit: 21 in the first trimester, 17 in the second trimester, and 10 in the third trimester. Forty-five had undetectable viral loads at delivery. The time lag between diagnosis of HIV and initiation of ART was 1 month for 31% and 3 months for 28.5%. Conclusions The time lag between diagnosis of HIV and initiation of ART was more than 1 month in 69% of the expectant mothers, which may have contributed to the failure in viral suppression. Implementation of HIV screening and a more effective means of communication between prenatal and HIV clinics are required to help reduce vertical transmission of the virus to neonates.