Rachael A. Lee

Cytomegalovirus appendicitis in solid organ transplant patients, two cases and a review

Cytomegalovirus (CMV) disease is a common complication following solid organ transplantation with a variety of gastrointestinal (GI) tract manifestations. CMV appendicitis, however, is a rare complication in a solid organ transplant patient, having been reported only once previously. We have recently seen two cases in solid organ transplant recipients at our institution, one a liver recipient and the other a heart recipient. Both patients underwent surgical resection. Pathologic evaluation of both resected appendices as well as polymerase chain reaction (PCR) amplification for CMV from the serum revealed the virus as the etiology. Both patients received induction intravenous ganciclovir followed by oral valganciclovir and have done well post-operatively. Tissue-invasive CMV disease should be considered in the differential diagnosis for solid organ transplant patients with symptoms suggesting acute or chronic appendicitis. Both PCR testing as well as pathologic review of tissue specimens should be considered to ensure accurate diagnosis and management.

Impact of Changes to the National Healthcare Safety Network (NHSN) Definition on Catheter-Associated Urinary Tract Infection (CAUTI) Rates in Intensive Care Units at an Academic Medical Center

1. Butler A, Olsen M, Merz L, Guth R, et al. Attributable costs of enterococcal bloodstream infections in a nonsurgical hospital cohort. Infect Control Hosp Epidemiol 2010;31:28–35. 2. Bodily M, McMullen K, Russo A, et al. Discontinuation of reflex testing of stool samples for vancomycin-resistant Enterococci resulted in increased prevalence. Infect Control Hosp Epidemiol 2013;34:838–840. 3. National Healthcare Safety Network (NHSH). 2016. Patient safety component manual. Centers for Disease Control and Prevention website. http://www.cdc.gov/nhsn/PDFs/pscManual/pcsManual_ current.pdf. Published 2016. Accessed August 4, 2016. 4. Hill AB. The environment and disease: association or causation? Proc R Soc Med 1965;58:295–300. 5. Muto C, Jernigan J, Ostrowsky B, et al. SHEA guideline for preventing nosocomial transmission of multidrug-resistant strains of Staphylococcus aureus and Enterococcus. Infect Control Hosp Epidemiol 2003;24:362–386. 6. Siegel JD, Rhinehart E, Jackson M, Chiarello L. Management of multidrug-resistant organisms in healthcare settings, 2006. Am J Infect Control 2007;35:S65–S194. 7. Calfee D, Gianetta E, Durbin L, Germanson T, Farr B. Control of endemic vancomycin-resistant Enterococcus among inpatients at a university hospital. Clin Infect Dis 2003;37:326–332. 8. Lucet JC, Armand-Lefevre L, Laurichesse JJ, et al. Rapid control of an outbreak of vancomycin-resistance Enterococci in a French university hospital. J Hosp Infect 2007;67:42–48. 9. Harris AD, McGregor JC, Perencevich EN, et al. The use and interpretation of quasi-experimental studies in medical informatics. J Am Med Inform Assoc 2006;13:16–23.

Evaluation of baseline corrected QT interval and azithromycin prescriptions in an academic medical center

BACKGROUND Azithromycin is used in the inpatient setting for a variety of conditions. In 2013, the US Food and Drug Administration released a warning regarding risk for corrected QT (QTc) prolongation and subsequent arrhythmias. Knowledge of inpatient prescribing patterns of QTc prolonging medications with respect to patient risk factors for adverse cardiovascular events can help recognize safe use in light of these new warnings. OBJECTIVE To assess inpatient prescribing patterns, risk factors for QTc prolongation, and relationship between drug-drug interactions and cardiac monitoring in patients receiving azithromycin. DESIGN Retrospective cohort study. PARTICIPANTS One hundred inpatients ≥ 19 years of age were randomly selected from 1610 patient encounters between October 2012 and April 2013 who were administered at least 1 dose of azithromycin. MEASUREMENTS Length of stay, reason for use, therapy duration, and concomitant medications were recorded. Telemetry charges and baseline electrocardiogram (ECG) prior to administration were assessed. RESULTS Seventy-nine percent of azithromycin use was empiric. Sixty-five percent of patients received a baseline ECG prior to prescribing azithromycin, of which 60% had borderline or abnormal QTc prolongation. Seventy-six percent of patients were prescribed 2 or more QTc prolonging medications, of which there were more abnormal ECGs at baseline (P = 0.03) despite having telemetry ordered less than half of the time. CONCLUSIONS In a cohort of hospitalized patients, azithromycin was prescribed despite risk factors for QTc prolongation and administration of interacting medications. Selection of azithromycin by providers appears to be independent from these risk factors, and education and vigilance to drug-drug interactions may be useful in limiting cardiac events with prescribing azithromycin.

Pseudo-outbreak of Brevundimonas diminuta Attributed to Contamination of Culture Medium Supplement

We report an epidemiological investigation of a cluster of Brevundimonas diminuta isolates cultured from sterile sites. Inoculation of supplement medium yielded growth of B. diminuta. Molecular typing indicated likely contamination of the lot. No B. diminuta was further isolated after replacement of the supplement with a new lot number. Infect Control Hosp Epidemiol 2017;38:598-601.

The Impact of 2015 NHSN Catheter-associated Urinary Tract Infection (CAUTI) Definition Change on Central Line-associated Bloodstream Infection (CLABSI) Rates and CLABSI Prevention Efforts at an Academic Medical Center

The 2015 changes in the catheter-associated urinary tract infection definition led to an increase in central line-associated bloodstream infections (CLABSIs) and catheter-related candidemia in some health systems due to the change in CLABSI attribution. However, our rates remained unchanged in 2015 and further declined in 2016 with the implementation of new vascular-access guidelines.Infect Control Hosp Epidemiol 2018;878-880.

Improvement of gram-negative susceptibility to fluoroquinolones after implementation of a pre-authorization policy for fluoroquinolone use: A decade-long experience

OBJECTIVE Due to concerns over increasing fluoroquinolone (FQ) resistance among gram-negative organisms, our stewardship program implemented a preauthorization use policy. The goal of this study was to assess the relationship between hospital FQ use and antibiotic resistance. DESIGN Retrospective cohort. SETTING Large academic medical center. METHODS We performed a retrospective analysis of FQ susceptibility of hospital isolates for 5 common gram-negative bacteria: Acinetobacter spp., Enterobacter cloacae, Escherichia coli, Klebsiella pneumoniae, and Pseudomonas aeruginosa. Primary endpoint was the change of FQ susceptibility. A Poisson regression model was used to calculate the rate of change between the preintervention period (1998-2005) and the postimplementation period (2006-2016). RESULTS Large rates of decline of FQ susceptibility began in 1998, particularly among P. aeruginosa, Acinetobacter spp., and E. cloacae. Our FQ restriction policy improved FQ use from 173 days of therapy (DOT) per 1,000 patient days to <60 DOT per 1,000 patient days. Fluoroquinolone susceptibility increased for Acinetobacter spp. (rate ratio [RR], 1.038; 95% confidence interval [CI], 1.005-1.072), E. cloacae (RR, 1.028; 95% CI, 1.013-1.044), and P. aeruginosa (RR, 1.013; 95% CI, 1.006-1.020). No significant change in susceptibility was detected for K. pneumoniae (RR, 1.002; 95% CI, 0.996-1.008), and the susceptibility for E. coli continued to decline, although the decline was not as steep (RR, 0.981; 95% CI, 0.975-0.987). CONCLUSIONS A stewardship-driven FQ restriction program stopped overall declining FQ susceptibility rates for all species except E. coli. For 3 species (ie, Acinetobacter spp, E. cloacae, and P. aeruginosa), susceptibility rates improved after implementation, and this improvement has been sustained over a 10-year period.

Impact of Infectious Disease Consultation on Clinical Management and Mortality in Patients with Candidemia

Candidemia has a high attributable mortality. The objective of this study was to determine the impact of infectious disease consultation on mortality and clinical outcomes in candidemia. Infectious disease consultation was associated with better adherence to guidelines and improved survival, even in patients with high Acute Physiology and Chronic Health Evaluation II scores.

Annals On Call - Diagnosing Sepsis: Untangling Confusion Around qSOFA and SIRS

In this episode of Annals On Call, Dr. Centor interviews Dr. Rachael A. Lee to try to help listeners untangle the confusion around qSOFA and SIRS, 2 tools to help clinicians decide if a patient has...

Impact of an Antimicrobial Stewardship Program Led OPAT Program on Clinical Complications and Frequency of Hospital Readmissions

Abstract Background Treatment of serious bacterial infections with Outpatient Parenteral Antibiotic Therapy (OPAT) has provided patients (patients) the opportunity to complete treatment safely and effectively, while avoiding complications, and prolonged hospitalization. Despite the benefits, considerable risks with drug-related and central venous catheter (CVC)-related complications exist. We sought to improve clinical outcomes of our program by implementing intensive monitoring in partnership with our antimicrobial stewardship program (ASP) with a goal of decreasing the frequency of complications as well as hospital readmission rates and lengths of stay (LOS). Methods A retrospective study was conducted including all patients discharged from the Birmingham VA Medical Center on OPAT from January 1, 2015 to December 31, 2016. The start date coincides with ASP development of a physician and pharmacist led OPAT program, working closely with home health agencies. Data collection included baseline demographics, antibiotic indication, antibiotic therapy received, and laboratory monitoring. Clinical outcomes included frequency and types of drug-related complications, CVC complications, hospital admission rate due to complications, and hospital days avoided. Results In the study period, 299 patients were discharged on OPAT. They were 96.9% male, and the average age was 64 (Table 1). The average number of hospital days avoided was 32.1. The most common indication was osteomyelitis (Table 1). There were 82 complications in 78 (26%) patients, almost half were acute kidney injury, defined as a rise in serum creatinine requiring a change in antibiotic dosing (Table 2). These led to 25 hospitalizations (32% of patients with complications, 8.3% overall) with another 5 patients being hospitalized for unrelated reasons. Conclusion Our medical center instituted an ASP led practice of closely monitoring and directing care with the local home health agencies due to concerns about patient safety. In doing so, we have realized a low rate of complications and an ability to manage the majority while remaining as an outpatient, with the exceptions of CVC-related complications and encephalopathy. Our data supports the center’s efforts and choice to dedicate resources to improving this increasingly popular treatment. Disclosures All authors: No reported disclosures.

The Clinical Impact of Daptomycin Non-susceptible Enterococcus Bacteremia in Hematologic Malignancy

Abstract Background Patients with hematologic malignancies are prone to colonization and infection with vancomycin-resistant Enterococcus (VRE), and VRE blood stream infections (BSI) in this population have been associated with a 30-day all-cause mortality approaching 40%. Daptomycin nonsusceptible Enterococci(DNSE) are on the rise, with institutional rates as high as 15%. The objective of this study was to determine the attributable mortality associated with resistance to daptomycin among VRE isolates. Methods We performed a retrospective cohort study of hematologic malignancy patients who developed either DNSE or daptomycin-susceptible VRE bacteremia between January 1, 2008 and December 31, 2016. Categorical variables were analyzed with chi-square or Fisher’s exact test and continuous variables were analyzed with a t-test or Wilcoxon rank sums test when appropriate. A p-value <0.05 was considered significant. Results 34 cases of DNSE and 65 cases of VRE were identified. There were no significant differences noted in demographic data. At time of bacteremia, both DNSE and VRE cohorts had similar APACHE II scores (medians for DNSE and VRE were 19). The DNSE cohort had longer periods of neutropenia prior to the diagnosis of bacteremia [median 32.1 days vs.. 19.3 days, OR 1.85 95% CI (0.75-1.60)]. Patients with DNSE had a longer time to initiation of appropriate antibiotics (median 3.5 days vs. 2.0 days, P = 0.01). There were similar rates of bone marrow transplantation (53 % of DNSE vs. 51% of VRE), however, DNSE cases were more likely to develop graft vs. host disease [OR 3.6 95% CI (1.07-12.38)]. In the 90-day period prior to bacteremia, daptomycin exposure occurred in only 12 (35.3%) of DNSE cases vs.. 1 (1.5%) VRE case [OR 34.9 95% CI (4.3-284.1)]. Median lengths of stay (LOS) were similarly high in both groups, however, DNSE patients were more likely to have a LOS over 50 days as compared with VRE (P = 0.048). 30-day mortality in the DNSE cohort was 50% compared with 38% in the VRE group (P = 0.12). Conclusion In a retrospective study, the 30-day mortality associated with DNSE bacteremia was 50%. Infection prevention interventions targeting this particular multi-drug-resistant organism are warranted in this vulnerable population. Disclosures All authors: No reported disclosures.