Ed Casabar

Antimicrobial misuse in patients with positive blood cultures

PURPOSE Inappropriate antimicrobial use was examined among a randomly and prospectively selected cohort of patients with at least one positive result of blood cultures. This misuse was then analyzed with respect to hospital charges and length of stay (LOS). PATIENTS AND METHODS The study consisted of 70 patients (average age, 58.5 years) who had not undergone bone marrow transplantation. Patient charts were reviewed daily for the following information: clinical signs and symptoms of infection, pertinent laboratory data, culture results, detailed data on each antimicrobial in every antimicrobial regimen and their appropriateness, hospital charges, LOS, diagnostic and procedure codes, and discharge status. Three severity of illness variables were generated. Inappropriate antimicrobial use was described according to one of 12 categories. RESULTS The percent of antimicrobial misuse, defined as the proportion of days of administration of antimicrobials on which one or more antimicrobials were judged inappropriate, was found to be 22.3%. After adjustment for severity of illness and diagnosis, this average inappropriateness correlated with 4.2 additional hospitalization days and

Early clinical experience with anidulafungin at a large tertiary care medical center.

5,368 additional hospital charges. CONCLUSION Our results cannot distinguish among several possible reasons for these associations, including direct causality (e.g., toxicity and prolonged hospitalization for antimicrobial use) and indirect links such as inappropriate utilization of other resources and influences of severity of illness on antimicrobial use not accounted for in our equations. Nevertheless, the magnitude of the association gives import to the desirability of further studies.

Clinical, microbiologic, and genetic determinants of persistent methicillin-resistant Staphylococcus aureus bacteremia

Study Objective. To evaluate early clinical experience with anidulafungin.

Use of cytomegalovirus intravenous immune globulin for the adjunctive treatment of cytomegalovirus in hematopoietic stem cell transplant recipients.

Methicillin-resistant Staphylococcus aureus bacteremia (MRSAB) often persists despite full susceptibility to vancomycin; therefore, associated factors were assessed. A retrospective cohort analysis of 222 patients with MRSAB treated with vancomycin was conducted; patients with persistent MRSAB (pMRSAB) were compared to those with nonpersistent bacteremia (NPB). Incidence of pMRSAB was 9%. More patients with vancomycin MIC = 2 mg/L had pMRSAB (16%) compared to patients with vancomycin MIC <2 mg/L (5%), P = 0.012. SCCmec type and Panton-Valentine leukocidin production were similar between patients with pMRSAB and NPB. There was no difference in vancomycin troughs, time to first dose, or area under the concentration-time curve/MIC between groups. More metastatic complications were observed in pMRSAB 63% versus NPB 32% (P = 0.005). Multivariate analysis found endocarditis (odds ratio [OR], 2.3; P = 0.021), complicated MRSAB (OR, 2.6; P = 0.009), vancomycin MIC = 2 (OR, 2.6; P = 0.009), and septic shock (OR 2.2 P = 0.031), which were independent predictors of pMRSAB.

Leech-Transmitted Ciprofloxacin-Resistant Aeromonas hydrophila

Study Objective. To describe the characteristics and clinical outcomes of hematopoietic stem cell transplant (HSCT) recipients who received adjunctive cytomegalovirus intravenous immune globulin (CMV‐IVIG) for probable or proven CMV disease.

Acute renal insufficiency during telavancin therapy in clinical practice

The use of medicinal leeches ( Hirudo medicinalis ) is effective in establishing venous outflow in congested flaps and replants.Leech therapy also has associated risks, including significant blood loss requiring transfusions and infections from Aeromonas , a gram-negative bacilli.Leeches maintain a symbiotic relationship with Aeromonas species, which are resident to their gut in order to digest blood. Aeromonas hydrophila infections can result in extensive soft-tissue infections and myonecrosis.To prevent this devastating nosocomial infection, ciprofloxacin and/or trimethoprim-sulfamethoxazole (TMP-SMX) are the most commonly used prophylactic antibiotics when patients undergo leech therapy.

Assessment of an alternative meropenem dosing strategy compared with imipenem-cilastatin or traditional meropenem dosing after cefepime failure or intolerance in adults with neutropenic fever.

OBJECTIVES To describe the tolerance to long-term telavancin therapy among inpatients as it relates to nephrotoxicity. METHODS Retrospective cohort study of adult patients who received telavancin at the Barnes-Jewish Hospital from 1 September 2009 to 1 December 2010. Patients who received less than three doses of telavancin, were on haemodialysis prior to telavancin administration or died within 48 h of initial telavancin administration were excluded. RESULTS Twenty-one patients received telavancin and met the inclusion criteria. Seven of 21 patients (33%) developed acute renal insufficiency during therapy. Patients who developed acute renal insufficiency had a mean glomerular filtration rate reduction of 56 mL/min/1.73 m(2). In the univariate analysis, high body mass index (P=0.025), use of intravenous contrast dye (P=0.017) and prior serum vancomycin trough levels >20 mg/L (P=0.017) were associated with developing acute renal insufficiency. Two patients required haemodialysis; two had persistent renal insufficiency. CONCLUSIONS Supratherapeutic vancomycin trough levels, high body mass index and receipt of intravenous contrast dye prior to telavancin therapy were associated with acute renal insufficiency.

Effective Antibiotic Conservation by Emergency Antimicrobial Stewardship During a Drug Shortage.

Study Objective. To compare clinical outcomes of patients receiving an alternative dosage of meropenem with those of patients receiving imipenem‐cilastatin or the traditional dosage of meropenem after failure of or intolerance to cefepime for treatment of febrile neutropenia.

Telavancin for refractory MRSA bacteraemia in intermittent haemodialysis recipients

We present the first description of an antimicrobial stewardship program (ASP) used to successfully manage a multi-antimicrobial drug shortage. Without resorting to formulary restriction, meropenem utilization decreased by 69% and piperacillin-tazobactam by 73%. During the shortage period, hospital mortality decreased (P=.03), while hospital length of stay remained unchanged. Infect Control Hosp Epidemiol 2017;38:356-359.

A randomized, prospective evaluation of an interventional program to discontinue intravenous antibiotics at two tertiary care teaching institutions.

Background Patients with end-stage renal disease (ESRD) requiring intermittent haemodialysis (IHD) are at high risk of MRSA bacteraemia (MRSA-B) and often fail first-line therapy. The safety, effectiveness and optimal dosing of telavancin for MRSA-B in this patient population are unclear. Objectives We aimed to describe clinical outcomes of telavancin in the treatment of refractory MRSA-B in patients with ESRD requiring IHD. Patients and methods This was a retrospective study of hospitalized patients at two tertiary care academic medical centres with recurrent or persistent (≥3 days) MRSA-B treated with telavancin monotherapy. Outcomes included duration of MRSA-B (pre-telavancin versus post-telavancin) and microbiological failure (duration of MRSA-B ≥3 days after initiation of telavancin). Results Telavancin dosed 10 mg/kg three times weekly post-IHD or 10 mg/kg every 48 h resulted in microbiological cure in 7/8 (87.5%) refractory MRSA-B cases. Telavancin monotherapy was associated with a significant reduction in median duration of bacteraemia [16 days pre-telavancin (IQR 8-19 days) versus 1 day post-telavancin (IQR 0-2 days); P = 0.018]. Telavancin was well tolerated by all patients and no adverse events were reported. Conclusions Telavancin was very safe and highly effective in the treatment of refractory MRSA-B in a cohort of patients with ESRD requiring IHD. These data support the utility of telavancin in the armamentarium against refractory MRSA-B, particularly in the high-risk IHD-dependent population.