Michelle T. Hecker

Effect of antibiotic therapy on the density of vancomycin-resistant enterococci in the stool of colonized patients.

BACKGROUND Colonization and infection with vancomycin-resistant enterococci have been associated with exposure to antibiotics that are active against anaerobes. In mice that have intestinal colonization with vancomycin-resistant enterococci, these agents promote high-density colonization, whereas antibiotics with minimal antianaerobic activity do not. METHODS We conducted a seven-month prospective study of 51 patients who were colonized with vancomycin-resistant enterococci, as evidenced by the presence of the bacteria in stool. We examined the density of vancomycin-resistant enterococci in stool during and after therapy with antibiotic regimens and compared the effect on this density of antianaerobic agents and agents with minimal antianaerobic activity. In a subgroup of 10 patients, cultures of environmental specimens (e.g., from bedding and clothing) were obtained. RESULTS During treatment with 40 of 42 antianaerobic-antibiotic regimens (95 percent), high-density colonization with vancomycin-resistant enterococci was maintained (mean [+/-SD] number of organisms, 7.8+/-1.5 log per gram of stool). The density of colonization decreased after these regimens were discontinued. Among patients who had not received antianaerobic antibiotics for at least one week, 10 of 13 patients who began such regimens had an increase in the number of organisms of more than 1.0 log per gram (mean increase, 2.2 log per gram), whereas among 10 patients who began regimens of antibiotics with minimal antianaerobic activity, there was a mean decrease in the number of enterococci of 0.6 log per gram (P=0.006 for the difference between groups). When the density of vancomycin-resistant enterococci in stool was at least 4 log per gram, 10 of 12 sets of cultures of environmental specimens had at least one positive sample, as compared with 1 of 9 sets from patients with a mean number of organisms in stool of less than 4 log per gram (P=0.002). CONCLUSIONS For patients with vancomycin-resistant enterococci in stool, treatment with antianaerobic antibiotics promotes high-density colonization. Limiting the use of such agents in these patients may help decrease the spread of vancomycin-resistant enterococci.

Unnecessary use of fluoroquinolone antibiotics in hospitalized patients

BackgroundFluoroquinolones are among the most commonly prescribed antimicrobials and are an important risk factor for colonization and infection with fluoroquinolone-resistant gram-negative bacilli and for Clostridium difficile infection (CDI). In this study, our aim was to determine current patterns of inappropriate fluoroquinolone prescribing among hospitalized patients, and to test the hypothesis that longer than necessary treatment durations account for a significant proportion of unnecessary fluoroquinolone use.MethodsWe conducted a 6-week prospective, observational study to determine the frequency of, reasons for, and adverse effects associated with unnecessary fluoroquinolone use in a tertiary-care academic medical center. For randomly-selected adult inpatients receiving fluoroquinolones, therapy was determined to be necessary or unnecessary based on published guidelines or standard principles of infectious diseases. Adverse effects were determined based on chart review 6 weeks after completion of therapy.ResultsOf 1,773 days of fluoroquinolone therapy, 690 (39%) were deemed unnecessary. The most common reasons for unnecessary therapy included administration of antimicrobials for non-infectious or non-bacterial syndromes (292 days-of-therapy) and administration of antimicrobials for longer than necessary durations (234 days-of-therapy). The most common syndrome associated with unnecessary therapy was urinary tract infection or asymptomatic bacteriuria (30% of all unnecessary days-of-therapy). Twenty-seven percent (60/227) of regimens were associated with adverse effects possibly attributable to therapy, including gastrointestinal adverse effects (14% of regimens), colonization by resistant pathogens (8% of regimens), and CDI (4% of regimens).ConclusionsIn our institution, 39% of all days of fluoroquinolone therapy were unnecessary. Interventions that focus on improving adherence with current guidelines for duration of antimicrobial therapy and for management of urinary syndromes could significantly reduce overuse of fluoroquinolones.

Contamination of Health Care Personnel During Removal of Personal Protective Equipment

IMPORTANCE Contamination of the skin and clothing of health care personnel during removal of personal protective equipment (PPE) contributes to dissemination of pathogens and places personnel at risk for infection. OBJECTIVES To determine the frequency and sites of contamination on the skin and clothing of personnel during PPE removal and to evaluate the effect of an intervention on the frequency of contamination. DESIGN, SETTING, AND PARTICIPANTS We conducted a point-prevalence study and quasi-experimental intervention from October 28, 2014, through March 31, 2015. Data analysis began November 17, 2014, and ended April 21, 2015. Participants included a convenience sample of health care personnel from 4 Northeast Ohio hospitals who conducted simulations of contaminated PPE removal using fluorescent lotion and a cohort of health care personnel from 7 study units in 1 medical center that participated in a quasi-experimental intervention that included education and practice in removal of contaminated PPE with immediate visual feedback based on fluorescent lotion contamination of skin and clothing. MAIN OUTCOMES AND MEASURES The primary outcomes were the frequency and sites of contamination on skin and clothing of personnel after removal of contaminated gloves or gowns at baseline vs after the intervention. A secondary end point focused on the correlation between contamination of skin with fluorescent lotion and bacteriophage MS2, a nonpathogenic, nonenveloped virus. RESULTS Of 435 glove and gown removal simulations, contamination of skin or clothing with fluorescent lotion occurred in 200 (46.0%), with a similar frequency of contamination among the 4 hospitals (range, 42.5%-50.3%). Contamination occurred more frequently during removal of contaminated gloves than gowns (52.9% vs 37.8%, P = .002) and when lapses in technique were observed vs not observed (70.3% vs 30.0%, P < .001). The intervention resulted in a reduction in skin and clothing contamination during glove and gown removal (60.0% before the intervention vs 18.9% after, P < .001) that was sustained after 1 and 3 months (12.0% at both time points, P < .001 compared with before the intervention). During simulations of contaminated glove removal, the frequency of skin contamination was similar with fluorescent lotion and bacteriophage MS2 (58.0% vs 52.0%, P = .45). CONCLUSIONS AND RELEVANCE Contamination of the skin and clothing of health care personnel occurs frequently during removal of contaminated gloves or gowns. Educational interventions that include practice with immediate visual feedback on skin and clothing contamination can significantly reduce the risk of contamination during removal of PPE.

Recurrence of vancomycin-resistant Enterococcus stool colonization during antibiotic therapy

OBJECTIVE To test the hypothesis that antibiotic therapy may promote recurrence of vancomycin-resistant Enterococcus (VRE) stool colonization in patients who have previously had three consecutive negative stool cultures obtained at least 1 week apart. DESIGN One-year prospective cohort study examining the effect of antibiotic therapy on recurrence and density of VRE stool colonization in patients who have cleared colonization. Pulsed-field gel electrophoresis (PFGE) was performed to determine whether recurrent VRE strains were the same clone as the previous colonizing strain. SETTING A Department of Veterans Affairs medical center including an acute care hospital and nursing home. PATIENTS All patients with at least one stool culture positive for VRE who subsequently had three consecutive negative stool cultures obtained at least 1 week apart. RESULTS Of the 16 patients who cleared VRE colonization, 13 received antibiotic therapy during the study period. Eight (62%) of the 13 patients who received antibiotics developed recurrent high-density VRE stool colonization (range, 4.9 to 9.1 log10 colony-forming units per gram) during a course of therapy. Five patients had VRE strains available for PFGE analysis; recurrent strains were unrelated to the prior strain in 3 patients, closely related in 1 patient, and indistinguishable in 1 patient. CONCLUSIONS Antibiotic therapy may be associated with recurrent high-density VRE stool colonization in many patients who have previously had three consecutive negative stool cultures. These patients should be screened for recurrent stool colonization when antibiotic therapy is administered.

Effect of a Stewardship Intervention on Adherence to Uncomplicated Cystitis and Pyelonephritis Guidelines in an Emergency Department Setting

Objective To evaluate adherence to uncomplicated urinary tract infections (UTI) guidelines and UTI diagnostic accuracy in an emergency department (ED) setting before and after implementation of an antimicrobial stewardship intervention. Methods The intervention included implementation of an electronic UTI order set followed by a 2 month period of audit and feedback. For women age 18 – 65 with a UTI diagnosis seen in the ED with no structural or functional abnormalities of the urinary system, we evaluated adherence to guidelines, antimicrobial use, and diagnostic accuracy at baseline, after implementation of the order set (period 1), and after audit and feedback (period 2). Results Adherence to UTI guidelines increased from 44% (baseline) to 68% (period 1) to 82% (period 2) (P≤.015 for each successive period). Prescription of fluoroquinolones for uncomplicated cystitis decreased from 44% (baseline) to 14% (period 1) to 13% (period 2) (P<.001 and P = .7 for each successive period). Unnecessary antibiotic days for the 200 patients evaluated in each period decreased from 250 days to 119 days to 52 days (P<.001 for each successive period). For 40% to 42% of cases diagnosed as UTI by clinicians, the diagnosis was deemed unlikely or rejected with no difference between the baseline and intervention periods. Conclusions A stewardship intervention including an electronic order set and audit and feedback was associated with increased adherence to uncomplicated UTI guidelines and reductions in unnecessary antibiotic therapy and fluoroquinolone therapy for cystitis. Many diagnoses were rejected or deemed unlikely, suggesting a need for studies to improve diagnostic accuracy for UTI.

Recurrent Infection with Epidemic Clostridium difficile in a Peripartum Woman Whose Infant Was Asymptomatically Colonized with the Same Strain

Figure 1. PCR ribotyping results demonstrating carriage of identical epidemic Clostridium difficile isolates in stool samples of a peripartum woman with recurrent C. difficile infection and her asymptomatic baby. The epidemic control strain and the isolates obtained from the mother and the baby had PCR amplification results positive for binary toxin gene cdtB and partial deletions of the tcdC gene, whereas the nonepidemic control strain did not. Lanes 1 and 6, 1 kb plus ladder; lane 2, epidemic control strain (restriction enzyme analysis type BI6, courtesy of Dale Gerding); lane 3, nonepidemic control strain (restriction enzyme analysis type J29 or 30); lane 4, isolate from the mother; lane 5, isolate from the baby. documents. New York: Columbia University, 1994. 7. Mendelson J, Jones RT. Clinical and pharmacological evaluation of buprenorphine and naloxone combination: why the 4:1 ratio for treatment. Drug Alcohol Depend 2003; 70(Suppl 1): 29–37. 8. US Food and Drug Administration. Subutex and Suboxone approved to treat opiate dependence. Available at: http://www.fda.gov/bbs/ topics/ANSWERS/2002/ANS01165.html. Accessed 10 December 2007. 9. Koch AL, Arfken CL, Schuster CR. Characteristics of US substance abuse treatment facilities adopting buprenorphine in its initial stage of availability. Drug Alcohol Depend 2006; 83: 274–8.

Overdiagnosis of Urinary Tract Infection and Underdiagnosis of Sexually Transmitted Infection in Adult Women Presenting to an Emergency Department

ABSTRACT Urinary tract infections (UTIs) and sexually transmitted infections (STIs) are commonly diagnosed in emergency departments (EDs). Distinguishing between these syndromes can be challenging because of overlapping symptomatology and because both are associated with abnormalities on urinalysis (UA). We conducted a 2-month observational cohort study to determine the accuracy of clinical diagnoses of UTI and STI in adult women presenting with genitourinary (GU) symptoms or diagnosed with GU infections at an urban academic ED. For all urine specimens, UA, culture, and nucleic acid amplification testing for Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis were performed. Of 264 women studied, providers diagnosed 175 (66%) with UTIs, 100 (57%) of whom were treated without performing a urine culture during routine care. Combining routine care and study-performed urine cultures, only 84 (48%) of these women had a positive urine culture. Sixty (23%) of the 264 women studied had one or more positive STI tests, 22 (37%) of whom did not receive treatment for an STI within 7 days of the ED visit. Fourteen (64%) of these 22 women were diagnosed with a UTI instead of an STI. Ninety-two percent of the women studied had an abnormal UA finding (greater-than-trace leukocyte esterase level, positive nitrite test result, or pyuria). The positive and negative predictive values of an abnormal UA finding were 41 and 76%, respectively. In this population, empirical therapy for UTI without urine culture testing and overdiagnosis of UTI were common and associated with unnecessary antibiotic exposure and missed STI diagnoses. Abnormal UA findings were common and not predictive of positive urine cultures.

Community-Acquired Pyelonephritis in Pregnancy Caused by KPC-Producing Klebsiella pneumoniae

ABSTRACT Carbapenem-resistant Enterobacteriaceae (CRE) usually infect patients with significant comorbidities and health care exposures. We present a case of a pregnant woman who developed community-acquired pyelonephritis caused by KPC-producing Klebsiella pneumoniae. Despite antibiotic treatment, she experienced spontaneous prolonged rupture of membranes, with eventual delivery of a healthy infant. This report demonstrates the challenge that CRE may pose to the effective treatment of common infections in obstetric patients, with potentially harmful consequences to maternal and neonatal health.

Survey of patients' knowledge and opinions regarding the use of indwelling urinary catheters.

In a survey of patients with short-term indwelling urinary catheters, 47% were aware that catheters cause urinary tract infections, 89% believed that catheters were not overused, and 68% preferred catheter placement rather than use of a bedside commode, bedpan, or diaper. Patient education is needed regarding the risks of urinary catheters.

To Add or Not to Add: Would the Addition of Dalbavancin to Formulary Decrease Admissions for Acute Bacterial Skin and Skin Structure Infections (ABSSSI)?

Abstract Background One of the major advantages of dalbavancin is that it may be administered as a single dose for the treatment of acute bacterial skin and skin structure infections (ABSSSI). Our objective was to determine the number (%) of patients with an ABSSSI diagnosis whose admission to a county hospital could have been avoided if dalbavancin was on formulary. Methods From November 2016 to April 2017, we reviewed encounters for adult patients seen in the emergency department or inpatient setting with a primary ABSSSI diagnosis. For those admitted, potential candidates for dalbavancin included those with ≥2 local signs/symptoms of ABSSSI AND ≥1 systemic sign of infection AND none of the exclusion criteria used in the DISCOVER 1 and 2 trials. Potential candidates were classified as qualifying for dalbavancin if they received IV antibiotics for ≥3 days but <14 days, had no Gram-negative or anaerobic organisms isolated, had no operative intervention nor ≥2 incision and drainage procedures, had a contraindication to linezolid, and did not require hospitalization for management of other comorbidities. Results Of 1203 patients with a primary diagnosis of ABSSSI, only 219 (18%) were admitted, of whom only 11 (5%) were classified as potential candidates for dalbavancin. The most common reasons admitted patients were excluded as potential candidates were not meeting signs and symptoms criteria (n = 147), age <18 years (n = 13), being admitted to the hospital for >14 days (n = 11), periorbital or joint cellulitis (n = 9), deep seated infection (n = 5), required admission for another reason (n = 5), and diabetic foot ulcer (n = 4). Of the 11 potential candidates, one qualified for dalbavancin based on our criteria. Conclusion At our hospital only a minority of patients with a primary diagnosis of ABSSSI were admitted and one ultimately met our criteria for dalbavancin use. Adding dalbavancin to our formulary would not have resulted in fewer admissions for patients with ABSSSI. Disclosures All authors: No reported disclosures.