Lisa E. Dumkow

Outcomes of Aminopenicillin Therapy for Vancomycin-Resistant Enterococcal Urinary Tract Infections.

ABSTRACT Vancomycin-resistant urinary tract infections are often challenging to treat. This retrospective cohort study compared outcomes between patients treated for vancomycin-resistant enterococcal urinary tract infection with an aminopenicillin and those treated with a non-β-lactam antibiotic. Inpatients treated with an enterococcus-active agent for their first symptomatic vancomycin-resistant enterococcal urinary tract infection between 1 January 2012 and 31 December 2013 were considered for inclusion. Patients with colonization, on hospice, or receiving comfort care only were excluded. The primary endpoint of clinical cure was defined as resolution of clinical symptoms, or symptom improvement to the extent that no additional antibacterial drug therapy was necessary, and lack of microbiologic persistence. Secondary endpoints of 30-day readmission or retreatment and 30-day all-cause mortality were also compared. A total of 316 urinary isolates were screened, and 61 patients with symptomatic urinary tract infection were included. Twenty (35%) of the 57 isolates tested were ampicillin susceptible. Thirty-one patients received an aminopenicillin, and 30 received a non-β-lactam. Rates of clinical cure for aminopenicillin versus non-β-lactam treatment were 26/31 (83.9%) and 22/30 (73.3%) (P = 0.315), respectively. Rates of 30-day readmission (6/31, or 19.4%, versus 9/30, or 30%, respectively; P = 0.334), 30-day retreatment (4/31, or 12.9%, versus 4/30, 13.3%, respectively; P = 0.960), and 30-day all-cause mortality (2/31, or 6.5%, versus 1/30, or 3.3%, respectively; P = 0.573) were also not significantly different between groups. Aminopenicillins may be a viable option for treating vancomycin-resistant urinary tract infection regardless of the organisms ampicillin susceptibility. Prospective validation with larger cohorts of patients should be considered.

Emergency Medicine Pharmacist Impact on Door-to-Needle Time in Patients With Acute Ischemic Stroke:

Background and Purpose: Decreased door-to-needle (DTN) time with tissue plasminogen activator (tPA) for acute ischemic stroke is associated with improved patient outcomes. Emergency medicine pharmacists (EMPs) can expedite the administration of tPA by assessing patients for contraindications, preparing, and administering tPA. The purpose of this study was to determine the impact of EMPs on DTN times and clinical outcomes in patients with acute ischemic stroke who receive tPA in the emergency department. Methods: A retrospective, single-center, cohort study of patients who received tPA between August 1, 2012, and August 30, 2014, was conducted to compare DTN times with or without EMP involvement in stroke care. Secondary outcomes included changes in neurological status as measured by the National Institutes of Health Stroke Scale (NIHSS), length of hospital stay, discharge disposition, symptomatic intracranial hemorrhage, and in-hospital all-cause mortality. Results: A total of 100 patients were included. The EMPs were involved in the care of 49 patients. The EMP involvement was associated with a significant improvement in DTN time (median 46 [interquartile range IQR: 34.5-67] vs 58 [IQR: 45-79] minutes; P = .019) and with receiving tPA within 45 minutes of arrival (49% vs 25%, odds ratio [OR]: 2.81 [95% confidence interval [CI]: 1.21-6.52]). National Institutes of Health Stroke Scale scores were significantly improved at 24 hours post-tPA in favor of the EMP group (median NIHSS 1 [IQR: 0-4] vs 2 [IQR: 1-9.25]; P = .047). Conclusions: The EMP involvement in initial stroke care was associated with a significant improvement in DTN time.

Impact of a stewardship-focused culture follow-up initiative on the treatment of pharyngitis in the emergency department and urgent care settings

A culture follow-up program with an emphasis on symptom assessment may limit antibiotic exposure in patients with Group A Streptococcus on throat culture. A quasi-experimental study of such patients was conducted in our Emergency Department and Urgent Care centers. During the prestewardship initiative phase (March 2011-June 2012), the standard of care for culture follow-up did not include symptom assessment prior to prescribing antibiotics. During the stewardship initiative phase (March 2015-June 2016), culture follow-up was completed with a focus on symptom assessment and antibiotic avoidance. Two-hundred eighty patients were included. Antibiotic prescribing at follow-up decreased from 97.0% to 71.3% (P < 0.001); overall appropriateness of therapy at follow-up, including symptom assessment, increased from 6.0% to 81.5% (P < 0.001). There was no difference in 72-h revisit between the pre- and poststewardship initiative groups (P = 0.121). This study demonstrated improved antimicrobial prescribing with initiation of a stewardship-focused culture follow-up program in the Emergency Department and Urgent Care centers.

Implementation of Rapid Diagnostic Testing without Active Stewardship Team Notification for Gram-Positive Blood Cultures in a Community Teaching Hospital.

In community hospitals, antimicrobial stewardship team notification of rapid diagnostic testing (RDT) results may not be feasible. A retrospective quasi-experimental study was conducted evaluating 252 adult inpatients with blood cultures positive for Gram-positive cocci in clusters (pre-RDT, n = 143; post-RDT, n = 109). ABSTRACT In community hospitals, antimicrobial stewardship team notification of rapid diagnostic testing (RDT) results may not be feasible. A retrospective quasi-experimental study was conducted evaluating 252 adult inpatients with blood cultures positive for Gram-positive cocci in clusters (pre-RDT, n = 143; post-RDT, n = 109). The median time to appropriate therapy was significantly shorter in the post-RDT group (15 versus 0 h, P < 0.001), and the mean length of stay for patients with coagulase-negative staphylococcus was significantly shorter (10.5 versus 7.7 days; P = 0.015).

Impact of an emergency medicine pharmacist on empiric antibiotic prescribing for pneumonia and intra-abdominal infections

Purpose: It is critical to engage ED providers in antimicrobial stewardship programs (ASP). Emergency medicine pharmacists (EMPs) play an important role in ASP by working with providers to choose empiric antimicrobials. This study aimed to determine the impact of an EMP on appropriate empiric antibiotic prescribing for community‐acquired pneumonia (CAP) and intra‐abdominal infections (CA‐IAI). Methods: A retrospective cohort study was conducted evaluating adult patients admitted with CAP or CA‐IAI. The primary outcome of this study was to compare guideline‐concordant empiric antibiotic prescribing when an EMP was present vs. absent. We also aimed to compare the impact of an EMP in an early‐ASP vs. established‐ASP. Results: 320 patients were included in the study (EMP n = 185, no‐EMP n = 135). Overall empiric antibiotic prescribing was more likely to be guideline‐concordant when an EMP was present (78% vs. 61%, p = 0.001); this was true for both the CAP (95% vs. 79%, p = 0.005) and CA‐IAI subgroups (62% vs. 44%, p = 0.025). Total guideline‐concordant prescribing significantly increased between the early‐ASP and established‐ASP (60% vs. 82.5%, p < 0.001) and was more likely when an EMP was present (early‐ASP: 68.3% vs. 45.8%, p = 0.005; established‐ASP: 90.5% vs. 73.7%, p = 0.005). Patients receiving guideline‐concordant antibiotics in the ED continued appropriate therapy upon admission 82.5% of the time vs. 18.8% if the ED antibiotic was inappropriate (p < 0.001). Conclusion: The presence of an EMP significantly improved guideline‐concordant empiric antibiotic prescribing for CAP and CA‐IAI in both an early and established ASP. Inpatient orders were more likely to be guideline‐concordant if appropriate therapy was ordered in the ED.

Reply to "Urinary Tract Infections: Resistance Is Futile".

We thank Dr. Wenzler and Dr. Danziger ([1][1]) for their comments on our recent paper ([2][2]) and appreciate their insightful perspective on the use of aminopenicillins for selected urinary tract infections (UTIs) caused by vancomycin-resistant enterococci. As they point out, our data provide