Ramzy H. Rimawi

The impact of penicillin skin testing on clinical practice and antimicrobial stewardship

BACKGROUND Penicillin skin testing (PST) is a simple and reliable way of diagnosing penicillin allergy. After being off the market for 4 years, penicilloyl-polylysine was reintroduced in 2009 as PRE-PEN. We describe the negative predictive value (NPV) of PST and the impact on antibiotic selection in a sample of hospitalized patients with a reported history of penicillin allergy. METHODS We introduced a quality improvement process at our 861-bed tertiary care hospital that used PST to guide antibiotic usage in patients with a history consistent with an immunoglobulin E (IgE)-mediated reaction to penicillin. Subjects with a negative PST were then transitioned to a β-lactam agent for the remainder of their therapy. NPV of skin testing was established at 24-hour follow-up. We are reporting the result of 146 patients tested between March 2012 and July 2012. RESULTS A total of 146 patients with a history of penicillin allergy and negative PST were treated with β-lactam antibiotics. Of these, only 1 subject experienced an allergic reaction to the PST. The remaining 145 patients tolerated a full course of β-lactam therapy without an allergic response, giving the PST a 100% NPV. We estimated that PST-guided antibiotic alteration for these patients resulted in an estimated annual savings of

Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome.

82,000. CONCLUSION Patients with a history of penicillin allergy who have a negative PST result are at a low risk of developing an immediate-type hypersensitivity reaction to β-lactam antibiotics. The increased use of PST may help improve antibiotic stewardship in the hospital setting.

Ceftaroline ‐ a cause for neutropenia

Objective:Antimicrobial stewardship programs have been shown to help reduce the use of unnecessary antimicrobial agents in the hospital setting. To date, there has been very little data focusing on high-use areas, such as the medical ICU. A prospective intervention was done to assess guideline compliance, antimicrobial expenditure, and healthcare cost when an infectious disease fellow interacts regularly with the medical ICU team. Design:A 3-month retrospective chart review was followed by a 3-month prospective intervention the following year. Two hundred forty-six total charts were reviewed to assess generally accepted guideline compliance, demographics, and microbiologic results. Setting:Twenty-four-bed medical ICU at an 861-bed tertiary care, university teaching hospital in North Carolina. Subjects:Patients receiving antibiotics in the medical ICU. Intervention:During the intervention period, the infectious disease fellow reviewed the charts, including physician notes and microbiology data, and discussed antimicrobial use with the medical ICU team. Measurements and Main Results:Antimicrobial use, treatment duration, Acute Physiology and Chronic Health Evaluation II scores, length of stay, mechanical ventilation days, and mortality rates were compared during the two periods. Results:No baseline statistically significant differences in the two groups were noted (i.e., age, gender, race, or Acute Physiology and Chronic Healthcare Evaluation II scores). Indications for antibiotics included healthcare-associated (53%) and community-acquired pneumonias (17%). Significant reductions were seen in extended-spectrum penicillins (p = 0.0080), carbapenems (p = 0.0013), vancomycin (p = 0.0040), and metronidazole (p = 0.0004) following the intervention. Antimicrobial modification led to an increase in narrow-spectrum penicillins (p = 0.0322). The intervention group had a significantly lower rate of treatments that did not correspond to guidelines (p < 0.0001). There was a reduction in mechanical ventilation days (p = 0.0053), length of stay (p = 0.0188), and hospital mortality (p = 0.0367). The annual calculated healthcare savings was

Precision Medicine for Critical Illness and Injury

89,944 in early antibiotic cessation alone. Conclusion:Active communication with an infectious disease practitioner can significantly reduce medical ICU antibiotic overuse by earlier modification or cessation of antibiotics without increasing mortality. This in turn can reduce healthcare costs, foster prodigious education, and strengthen relations between the subspecialties.

A case of Exophiala oligosperma successfully treated with voriconazole.

The US Food and Drug Administration approved ceftaroline in 2010 for the treatment of community‐acquired pneumonia and skin and soft‐tissue infections. The most common adverse reactions are diarrhoea, nausea and rash. To present the first case of neutropenia directly related to ceftaroline.

Disseminated Herpes Simplex Virus with Fulminant Hepatitis.

Precision medicine aims to identify, select, and schedule therapies that are most likely to yield a favorable outcome for an individual patient (1). Conventional and precision approaches may differ according to the choices of drug, device or operation; to the intensities of the chosen treatments; an

Correlation between Methicillin-Resistant Staphylococcus aureus Nasal Sampling and S. aureus Pneumonia in the Medical Intensive Care Unit

Exophiala oligosperma is an uncommon pathogen associated with human infections, predominantly in immunocompromised hosts. Case reports of clinical infections related to E. oligosperma have been limited to 6 prior publications, all of which have shown limited susceptibility to conventional antifungal therapies, including amphotericin B, itraconazole, and fluconazole. We describe the first case of an E. oligosperma induced soft-tissue infection successfully treated with a 3-month course of voriconazole without persisting lesions.

Hunting For Tularaemia – A Review of Cases in North Carolina

Disseminated herpes simplex virus (HSV) is a rare cause of acute fulminant liver failure. We hereby present a case series of three patients with acute disseminated HSV with necrotizing hepatitis successfully treated with a week course of acyclovir. Early empiric administration of acyclovir therapy while awaiting confirmatory tests is critical in this potentially lethal disease.

Just Say "Stop": Avoiding Prolonged Empiric Antibiotics.

Pneumonia in the Medical Intensive Care Unit Author(s): Ramzy H. Rimawi, MD; Keith M. Ramsey, MD; Kaushal B. Shah, MD; Paul P. Cook, MD Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 5 (May 2014), pp. 590-593 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/675838 . Accessed: 08/04/2014 23:04

Expanding the pool of healthcare providers to perform penicillin skin testing in the ICU.

Human infections with Francisella tularensis can be acquired via numerous routes, including ingestion, inhalation, arthropod bite or direct contact with infected animals. Since 1991, there have been 25 reported cases of tularaemia in North Carolina, most of which were associated with rabbit hunting or cat bites. We present two adults cases of pulmonary and oropharyngeal tularaemia and review the reported cases since 1991–2013. We also present the fifth case of pulmonary empyema. While cavitary pneumonias are primarily treated with drainage, we illustrate a case of cavitary pneumonia associated with tularaemia successfully treated with oral ciprofloxacin after drainage. Tularaemia should be considered in patients with a perplexing radiographic image, animal exposure and lack of response to conventional empiric broad‐spectrum antibiotics. Even in serious cases of pneumonic tularaemia, fluoroquinolones may provide a suitable alternative to aminoglycosides.