Kerry M. Bommarito

A Retrospective Comparison of Ceftriaxone Versus Oxacillin for Osteoarticular Infections Due to Methicillin-Susceptible Staphylococcus aureus

BACKGROUND Antistaphylococcal penicillins are the treatment of choice for methicillin-susceptible Staphylococcus aureus (MSSA) infection. Ceftriaxone can be dosed once daily and is less expensive for outpatient therapy than oxacillin. We compared patient outcomes of MSSA osteoarticular infections treated with ceftriaxone versus oxacillin. METHODS We conducted a retrospective cohort study of patients with MSSA osteoarticular infections at a tertiary care hospital from January 2005 to April 2010. We collected demographic, clinical, and outcome data including treatment-related adverse events. Successful treatment (clinical improvement; improved follow-up markers and imaging; no readmission for treatment) was compared at 3-6 months and >6 months after completion of intravenous antibiotics. RESULTS In total, 124 patients had an MSSA osteoarticular infection; 64 (52%) had orthopedic hardware involvement. Of those patients, 74 (60%) received ceftriaxone and 50 (40%) received oxacillin. Oxacillin was more often discontinued due to toxicity (9 of 50 [18%] oxacillin vs 3 of 74 [4%] ceftriaxone; P = .01). At 3-6 and >6 months, data for 97 and 88 patients, respectively, were available for analysis. Treatment success was similar at 3-6 months (50 of 60 [83%] ceftriaxone vs 32 of 37 [86%] oxacillin; P = .7) and >6 months (43 of 56 [77%] ceftriaxone vs 26 of 32 [81%] oxacillin; P = .6). After intravenous antibiotics, 56 (45%) patients received long-term suppression with oral antibiotics (31 of 74 [42%] ceftriaxone vs 25 of 50 [50%] oxacillin; P = .4). CONCLUSIONS In this comparison of ceftriaxone versus oxacillin for MSSA osteoarticular infections, there was no difference in treatment success at 3-6 and >6 months following the completion of intravenous antibiotics. Patients receiving oxacillin were more likely to have it discontinued due to toxicity.

Risk managers, physicians, and disclosure of harmful medical errors.

BACKGROUND Physicians are encouraged to disclose medical errors to patients, which often requires close collaboration between physicians and risk managers. METHODS An anonymous national survey of 2,988 healthcare facility-based risk managers was conducted between November 2004 and March 2005, and results were compared with those of a previous survey (conducted between July 2003 and March 2004) of 1,311 medical physicians in Washington and Missouri. Both surveys included an error-disclosure scenario for an obvious and a less obvious error with scripted response options. RESULTS More risk managers than physicians were aware that an error-reporting system was present at their hospital (81% versus 39%, p < .001) and believed that mechanisms to inform physicians about errors in their hospital were adequate (51% versus 17%, p < .001). More risk managers than physicians strongly agreed that serious errors should be disclosed to patients (70% versus 49%, p < .001). Across both error scenario, risk managers were more likely than physicians to definitely recommend that the error be disclosed (76% versus 50%, p < .001) and to provide full details about how the error would be prevented in the future (62% versus 51%, p < .001). However, physicians were more likely than risk managers to provide a full apology recognizing the harm caused by the error (39% versus 21%, p < .001). CONCLUSIONS Risk managers have more favorable attitudes about disclosing errors to patients compared with physicians but are less supportive of providing a full apology. These differences may create conflicts between risk managers and physicians regarding disclosure. Health care institutions should promote greater collaboration between these two key participants in disclosure conversations.

Prevalence of qacA/B Genes and Mupirocin Resistance Among Methicillin-Resistant Staphylococcus aureus (MRSA) Isolates in the Setting of Chlorhexidine Bathing Without Mupirocin

OBJECTIVE We aimed to determine the frequency of qacA/B chlorhexidine tolerance genes and high-level mupirocin resistance among MRSA isolates before and after the introduction of a chlorhexidine (CHG) daily bathing intervention in a surgical intensive care unit (SICU). DESIGN Retrospective cohort study (2005-2012) SETTING: A large tertiary-care center PATIENTS Patients admitted to SICU who had MRSA surveillance cultures of the anterior nares METHODS A random sample of banked MRSA anterior nares isolates recovered during (2005) and after (2006-2012) implementation of a daily CHG bathing protocol was examined for qacA/B genes and high-level mupirocin resistance. Staphylococcal cassette chromosome mec (SCCmec) typing was also performed. RESULTS Of the 504 randomly selected isolates (63 per year), 36 (7.1%) were qacA/B positive (+) and 35 (6.9%) were mupirocin resistant. Of these, 184 (36.5%) isolates were SCCmec type IV. There was a significant trend for increasing qacA/B (P=.02; highest prevalence, 16.9% in 2009 and 2010) and SCCmec type IV (P<.001; highest prevalence, 52.4% in 2012) during the study period. qacA/B(+) MRSA isolates were more likely to be mupirocin resistant (9 of 36 [25%] qacA/B(+) vs 26 of 468 [5.6%] qacA/B(-); P=.003). CONCLUSIONS A long-term, daily CHG bathing protocol was associated with a change in the frequency of qacA/B genes in MRSA isolates recovered from the anterior nares over an 8-year period. This change in the frequency of qacA/B genes is most likely due to patients in those years being exposed in prior admissions. Future studies need to further evaluate the implications of universal CHG daily bathing on MRSA qacA/B genes among hospitalized patients.

Randomized Controlled Trial to Determine the Impact of Probiotic Administration on Colonization With Multidrug-Resistant Organisms in Critically Ill Patients.

This was a randomized controlled pilot study of Lactobacillus rhamnosus GG versus standard of care to prevent gastrointestinal multidrug-resistant organism colonization in intensive care unit patients. Among 70 subjects, there were no significant differences in acquisition or loss of any multidrug-resistant organisms (P>.05) and no probiotic-associated adverse events.

Risk for Clostridium difficile infection after allogeneic hematopoietic cell transplant remains elevated in the postengraftment period

Background Clostridium difficile infection (CDI) is a frequent cause of diarrhea among allogeneic hematopoietic cell transplant (HCT) recipients. It is unknown whether risk factors for CDI vary by time posttransplant. Methods We performed a 3-year prospective cohort study of CDI in allogeneic HCT recipients. Participants were enrolled during their transplant hospitalizations. Clinical assessments were performed weekly during hospitalizations and for 12 weeks posttransplant, and monthly for 30 months thereafter. Data were collected through patient interviews and chart review, and included CDI diagnosis, demographics, transplant characteristics, medications, infections, and outcomes. CDI cases were included if they occurred within 1 year of HCT and were stratified by time from transplant. Multivariable logistic regression was used to determine risk factors for CDI. Results One hundred eighty-seven allogeneic HCT recipients were enrolled, including 63 (34%) patients who developed CDI. 38 (60%) CDI cases occurred during the preengraftment period (days 0-30 post-HCT) and 25 (40%) postengraftment (day >30). Lack of any preexisting comorbid disease was significantly associated with lower risk of CDI preengraftment (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.1-0.9). Relapsed underlying disease (OR, 6.7; 95% CI, 1.3-33.1), receipt of any high-risk antimicrobials (OR, 11.8; 95% CI, 2.9-47.8), and graft-versus-host disease (OR, 7.8; 95% CI, 2.0-30.2) were significant independent risk factors for CDI postengraftment. Conclusions A large portion of CDI cases occurred during the postengraftment period in allogeneic HCT recipients, suggesting that surveillance for CDI should continue beyond the transplant hospitalization and preengraftment period. Patients with continued high underlying severity of illness were at increased risk of CDI postengraftment.

An evaluation of the prevalence of vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA) in hospital food

This prospective cohort study evaluated the presence of MRSA and VRE in the food of hospitalized patients. 149 patients were enrolled and 910 food specimens cultured; 3.2% were positive for MRSA and 2.4% positive for VRE, from a variety of food types.

Epidemiology and outcomes of Clostridium difficile infection in allogeneic hematopoietic cell and lung transplant recipients

Clostridium difficile infection (CDI) is a common complication of lung and allogeneic hematopoietic cell (HCT) transplant, but the epidemiology and outcomes of CDI after transplant are poorly described.

TIMING AND CAUSES OF READMISSION WITHIN 30-DAYS OF DISCHARGE FROM A HEART FAILURE HOSPITALIZATION IN A LARGE MULTI-STATE HEALTHCARE COST AND UTILIZATION PROJECT STATE INPATIENT DATABASE

Identifying 30-day readmission diagnoses after Heart Failure (HF) hospitalization is paramount given current hospital performance measures. The 2007-2011 California, New York, and Florida Healthcare Cost and Utilization Project State Inpatient Databases were used to identify adults aged ≥ 18

307Prevalence of qac A/B among Methicillin-Resistant Staphylococcus aureus (MRSA) Isolates Recovered from Active Surveillance Cultures of the Anterior Nares in the Setting of Chlorhexidine Bathing

307. Prevalence of qac A/B among Methicillin-Resistant Staphylococcus aureus (MRSA) Isolates Recovered from Active Surveillance Cultures of the Anterior Nares in the Setting of Chlorhexidine Bathing Martin Prager, MD; MeghanWallace, BA; Kerry M. Bommarito, PhD, MPH; CareyAnn Burnham, PhD, Pediatrics; David K. Warren, MD, MPH, FIDSA, FSHEA; Infectious Diseases, Washington University in St. Louis, St Louis, MO; Pathology and Immunology, Washington University School of Medicine, St. Louis, MO; Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO; Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, MO