Jennifer Pisano

Laryngectomy Complications Are Associated with Perioperative Antibiotic Choice

Objective To assess hospital- and physician-level variation in pattern of perioperative antibiotic use for laryngectomy and the relationship between pattern of antibiotic use and surgical site infection (SSI), wound dehiscence, and antibiotic-induced complications. Study Design Retrospective analysis of University HealthSystem Consortium data. Setting Academic medical centers and affiliated hospitals. Subjects and Methods Elective admissions for laryngectomy from 2008 to 2011 and associated 30-day readmissions were analyzed with multivariate logistic regression models. Results There were 439 unique antibiotic regimens (agents and duration) identified over the first 4 days of the 1865 admissions included in this study. Ampicillin/sulbactam, cefazolin + metronidazole, and clindamycin were the most common agents given on the day of surgery. Clindamycin was independently associated with higher odds of SSI (odds ratio [OR] = 3.87, 95% confidence interval [CI] = 2.31-6.49]), wound dehiscence (OR = 3.42, 95% CI = 2.07-5.64), and antibiotic-induced complications (OR = 3.01, 95% CI = 1.59-5.67) when given alone; it was also associated with higher odds of SSI (OR = 2.69, 95% CI = 1.43-5.05) and antibiotic-induced complications (OR = 2.20, 95% CI = 1.04-4.64) when given with other agents. These effects were stronger in a subsample of high-volume physicians and hospitals. Conclusion There is substantial variability in perioperative antibiotic strategies for laryngectomy. Clindamycin was associated with much higher odds of short-term complications as compared to other common regimens. Based on these data, clinical trials should be planned to firmly establish the most effective and cost-effective antibiotic management for laryngectomy and determine potential alternatives to clindamycin for penicillin-allergic patients.

Evaluation of risk factors for vancomycin-resistant Enterococcus bacteremia among previously colonized hematopoietic stem cell transplant patients

Hematopoietic stem cell transplantation (HSCT) recipients colonized with vancomycin‐resistant Enterococcus (VRE) may have an increased risk of developing VRE bacteremia. Identification of risk factors for the development of subsequent VRE bacteremia among colonized HSCT recipients is necessary to predict which patients may benefit the most from receiving anti‐VRE antibiotic therapy as part of an initial antimicrobial regimen when gram‐positive bacteremia is suspected.

The effect of broader, directed antimicrobial prophylaxis including fungal coverage on perioperative infectious complications after radical cystectomy.

OBJECTIVES Radical cystectomy (RC) with urinary diversion has a significant risk of infection. In an effort to decrease the rate of infectious complications, we instituted a broader, culture-based preoperative antimicrobial regimen, including fungal coverage, and studied its effect on infectious complications after RC. MATERIALS AND METHODS In May 2013, antimicrobial prophylaxis for RC was changed at our institution after review of previous positive cultures. Ampicillin-sulbactam 3g, gentamicin 4mg/kg, and fluconazole 400mg replaced cefoxitin. Patients undergoing RC from May 2011 to May 2014 were included. Before and after implementation of the new regimen, 30-day infectious complications (positive blood culture, urinary tract infection, wound infection, abscess, and pneumonia) and adverse events (Clostridium difficile, readmission, and mortality) were compared. Multivariate logistic regression was used to identify independent risk factors for infection while controlling for covariates. RESULTS In total, 386 patients were studied (258 before the change and 128 after). The overall infection rate decreased with the new regimen (41% vs. 30%, P = 0.043) with improvements in wound (14% vs. 6%, P = 0.025) and fungal (10% vs. 3%, P = 0.021) infections. Median length of stay decreased from 8 (interquartile range [IQR]: 7-12) to 7 (IQR: 7-10) days (P = 0.008). On multivariate analysis, the new regimen decreased the risk of infections (odds ratio [OR] = 0.58, 95% CI [0.35-0.99], P = 0.044) whereas body mass index, operating room time, smoking, and total parenteral nutrition increased the risk (all P< 0.05). CONCLUSIONS Risk factors for infection after RC include body mass index, operating room time, smoking, and total parenteral nutrition use. Changing from cefoxitin to broader, culture-directed antimicrobial prophylaxis, based on institutional data to include antifungal coverage, decreased postoperative infections.

Multicentre study of posaconazole delayed-release tablet serum level and association with hepatotoxicity and QTc prolongation

Objectives The association of posaconazole serum concentrations and toxicity is unclear. An assessment of whether levels obtained with the delayed-release tablet (DRT) formulation are correlated with abnormal liver function test (LFT) results and/or QTc prolongation was undertaken. Methods This was a multicentre, retrospective, observational study of adult patients with cancer between 26 November 2013 and 14 November 2014. Patients were included if they received posaconazole DRT with a posaconazole level obtained between days 5 and 14. Clinical data, including demographics, hepatotoxic medications, posaconazole levels, LFTs and QTc intervals, were obtained. Association of factors with changes in LFTs and QTc prolongation was assessed using linear and logistic regression. Results One hundred and sixty-six study patients were included. The median posaconazole level was 1250 (range 110-4220) ng/mL and the median time until level was 6 (range 5-14) days. There was a statistically significant increase in AST ( P  <   0.001), ALT ( P  <   0.001), alkaline phosphatase (ALK) ( P  <   0.001), total bilirubin (TBILI) ( P  <   0.001) and QTc ( P  =   0.05) from baseline. Posaconazole levels were not associated with increases in AST [β (SE) = -0.33 (2.2), P  =   0.88], log ALT [β (SE) = -0.02 (0.03), P  =   0.63], ALK [β (SE) = 2.2 (2.9), P  =   0.46] and TBILI [β (SE) = -0.01 (0.04), P  =   0.88]. For each additional hepatotoxic medication, there was a mean change in TBILI of 0.13 mg/dL ( P  =   0.02) and ALK of 7.1 U/L ( P  =   0.09). No statistically significant association between posaconazole level and QTc interval prolongation was found. Conclusions We did not identify an association between posaconazole serum concentrations and LFT elevations or QTc prolongation. However, some LFTs were found to increase with more hepatotoxic medications administered.

Comparison of turnaround time and time to oseltamivir discontinuation between two respiratory viral panel testing methodologies

Respiratory infections contribute to many Emergency Department visits and hospitalizations, resulting in a high healthcare burden (Neuzil et al., 2003; Schull et al., 2005). Rapid detection of respiratory pathogens in patients presenting with symptoms of an upper respiratory tract infection is crucial for timely determination of optimal antimicrobial management, avoidance of unnecessary evaluations and implementation of transmission-reducing infection control practices. Rapid viral testing can also result in cost savings to the healthcare system through reduction in Emergency Department boarding time and decreased duration of empiric antiviral therapy (Schull et al., 2005). With increased emphasis on antimicrobial stewardship in hospitals to facilitate improved clinical and economic outcomes with antimicrobial therapy, the implementation of rapid diagnostics for laboratory identification of pathogens is of great interest (Bauer et al., 2014). Multiplex PCR is a highly sensitive molecular method for accurate detection of respiratory pathogens and provides a more rapid turnaround time (TAT) compared with other respiratory viral testing methodologies. Our microbiology laboratory switched from the Luminex xTAG respiratory viral panel (RVP) (http://www.luminexcorp.com), which detects 12 respiratory viruses with an assay time of 8.5 h, performed two to three times per week to the Biofire Diagnostics FilmArray respiratory panel (RP) (http://filmarray.com), which detects 17 respiratory viral and three bacterial targets with an assay time of 1.2 h, performed 24 h a day/7 days per week. We compared the TAT between the two RVPs performed at different frequencies and determined the time to discontinuation of empiric oseltamivir among patients testing negative for influenza. All adult patients with an RVP test result reported between 1 December 2011 and 28 February 2012 performed on Luminex xTAG RVP (two to three times per week) and 1 December 2012 and 28 February 2013 performed on FilmArray RP (24 h a day/7 days per week) were evaluated for mean TAT. The mean TAT for the Luminex xTAG RVP (two to three times per week) between 1 December 2011 and 28 February 2012 (n = 230 assays) was 46.4 h compared with a mean TAT of 3.1 h (P<0.001) for FilmArray RP (24 h a day/7 days per week) between 1 December 2012 and 28 February 2013 (n = 872 assays) (Fig. 1). The mean time to discontinuation of empiric oseltamivir amongst patients with an RVP negative for influenza was 4 and 2 days for the Luminex xTAG RVP (n = 42) and FilmArray RP (n = 75) groups, respectively (P<0.001). The reduction in mean time to discontinuation of empiric oseltamivir resulted in cost savings of ~US

Use of Pneumococcal Vaccine in Adults

34.16 per patient (using a wholesale acquisition cost for oseltamivir of US

Guideline compliance and clinical outcomes among patients with Staphylococcus aureus bacteremia with infectious diseases consultation in addition to antimicrobial stewardship-directed review

8.54 per dose), which during the 2012–2013 peak influenza season would be an overall cost saving of US

Impact of a clinical pathway on appropriate empiric vancomycin use in cancer patients with febrile neutropenia.

2527.84. The amount of oseltamivir utilized after we began using the FilmArray RP (24 h a day/7 days per week) would cost US

Candida dubliniensis Pneumonia: A Case Report and Review of Literature

9564.80 (if all 112 influenza-positive patients received the standard 75 mg every 12 h dose for a duration of 5 days), in addition to US

Incidence and predictors of respiratory viral infections by multiplex PCR in allogeneic hematopoietic cell transplant recipients 50 years and older including geriatric assessment

2527.84 for those that would have received empiric therapy for a duration of 2 days prior to discontinuation following a negative influenza result, totalling US