Oct 302014
 
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Antibiotic-resistant gram-negative bacterial infections in patients with cancer.

Clin Infect Dis. 2014 Nov 15;59 Suppl 5:S335-9

Authors: Perez F, Adachi J, Bonomo RA

Abstract
Patients with cancer are at high risk for infections caused by antibiotic resistant gram-negative bacteria. In this review, we summarize trends among the major pathogens and clinical syndromes associated with antibiotic resistant gram-negative bacterial infection in patients with malignancy, with special attention to carbapenem and expanded-spectrum β-lactam resistance in Escherichia coli, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Stenotrophomonas maltophilia-all major threats to our cancer patients. Optimal therapy for these antibiotic-resistant pathogens still remains to be determined.

PMID: 25352627 [PubMed - in process]

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Oct 112014
 

Is Bacteremic Sepsis Associated with Higher Mortality in Transplant Recipients than in Non-Transplant Patients? A Matched Case-Control Propensity-Adjusted Study.

Clin Infect Dis. 2014 Oct 9;

Authors: Kalil AC, Syed A, Rupp ME, Chambers H, Vargas L, Maskin A, Miles CD, Langnas A, Florescu DF

Abstract
BACKGROUND:  Sepsis is a serious solid organ transplant (SOT) complication. Evidence on survival differences between SOT and non-SOT patients with sepsis is lacking.
METHODS:  Matched, case-control propensity-adjusted study. Conditional logistic regression was performed for risk factor analysis; Cox proportional hazards regression for survival analysis.
RESULTS:  A total of 369 patients (123 cases; 246 controls) diagnosed with blood culture proven sepsis were matched 1:2 by age, gender, and hospital location. The distribution of allografts: 36.6% kidney, 34.1% liver, 13% kidney-pancreas, 7.3% small bowel/liver, 5.7% heart/lung, and 3.3% multivisceral. The conditional logistic regression showed that the following factors were significantly more frequently associated with SOT compared to non-SOT: higher number of comorbidities OR=8.2 [95%CI 1.48 to 45.44] (p=0.016); higher SOFA score OR=1.2 [95%CI 1.07 to 1.32] (p=0.001); presence of nosocomial infection OR=36.3 [95%CI 9.71 to 135.96] (p<0.0001); inappropriate initial antibiotics OR=0.04 [95%CI 0.006 to 0.23] (p<0.0001); and lower white blood cell count OR=0.93 [95%CI 0.89 to 0.97] (p<0.0001). Cox proportional hazards regression showed that after all adjustments for clinical presentation, severity of illness and types of infection, SOT recipients with sepsis had a significantly lower risk of death at 28 days: HR=0.22 [95%CI 0.09 to 0.54] (p=0.001), and at 90 days: HR=0.43 [95%CI 0.20 to 0.89] (P=0.025).
CONCLUSIONS:  The 28-day and 90-day mortality were significantly decreased for transplant recipients compared with non-transplant patients. These findings suggest that the immunosuppression associated with transplantation may provide a survival advantage to transplant recipients with sepsis through modulation of the inflammatory response.

PMID: 25301215 [PubMed - as supplied by publisher]

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Oct 092014
 
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Single-dose Oritavancin Compared to 7-10 days of Vancomycin in the Treatment of Gram-Positive Acute Bacterial Skin and Skin Structure Infections; the SOLO II Non-inferiority Study.

Clin Infect Dis. 2014 Oct 6;

Authors: Corey GR, Good S, Jiang H, Moeck G, Wikler M, Green S, Manos P, Keech R, Singh R, Heller B, Bubnova N, O'Riordan W, for the SOLO II Investigators

Abstract
BACKGROUND:  Oritavancin is a lipoglycopeptide antibiotic with rapid bactericidal activity against gram-positive bacteria. Its concentration dependent activity and long half-life allow for single-dose treatment.
METHODS:  In a randomized, double-blind trial, adults with acute bacterial skin and skin structure infections received either a single IV 1200 mg dose of oritavancin or 7 to 10 days of twice-daily vancomycin. Three efficacy endpoints were tested for non-inferiority: 1) primary composite endpoint at 48 to 72 hours (cessation of spreading or reduction in lesion size, absence of fever, and no rescue antibiotic); 2) investigator-assessed clinical cure 7 to 14 days after end of treatment; and 3) ≥20% reduction in lesion area at 48 to 72 hours.
RESULTS:  A total of 503 and 502 patients comprised the modified intent to treat (mITT) population for oritavancin and vancomycin, respectively. All three efficacy endpoints met the 10% non-inferiority margin: the primary composite endpoint, 80.1% vs 82.9%; [95% confidence interval (CI): -7.5, 2.0], investigator-assessed clinical cure, 82.7% vs 80.5%, [CI: -2.6, 7.0] and proportion of patients attaining ≥20% reduction in lesion area, 85.9% vs 85.3%, [CI: -3.7, 5.0] for oritavancin vs vancomycin respectively. Efficacy outcomes by pathogen, including methicillin-resistant Staphylococcus aureus and the frequency of adverse events were similar between treatment groups.
CONCLUSIONS:  A single 1200 mg dose of oritavancin was non-inferior to 7 to 10 days of vancomycin in treating ABSSSI caused by gram-positive pathogens, and was well tolerated. Oritavancin provides a single-dose alternative to multi-dose therapies for the treatment of ABSSSI. Trial registration. ClinicalTrials.gov identifier: NCT01252732.

PMID: 25294250 [PubMed - as supplied by publisher]

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Sep 282014
 

Antimicrobial Stewardship: Philosophy Versus Practice.

Clin Infect Dis. 2014 Oct 15;59(suppl 3):S112-S121

Authors: Dodds Ashley ES, Kaye KS, DePestel DD, Hermsen ED

Abstract
To promote the judicious use of antimicrobials and preserve their usefulness in the setting of growing resistance, a number of policy-making bodies and professional societies have advocated the development of antimicrobial stewardship programs. Although these programs have been implemented at many institutions in the United States, their impact has been difficult to measure. Current recommendations advocate the use of both outcome and process measures as metrics for antimicrobial stewardship. Although patient outcome metrics have the greatest impact on the quality of care, the literature shows that antimicrobial use and costs are the indicators measured most frequently by institutions to justify the effectiveness of antimicrobial stewardship programs. The measurement of more meaningful outcomes has been constrained by difficulties inherent to these measures, lack of funding and resources, and inadequate study designs. Antimicrobial stewardship can be made more credible by refocusing the antimicrobial review process to target specific disease states, reassessing the usefulness of current metrics, and integrating antimicrobial stewardship program initiatives into institutional quality and safety efforts.

PMID: 25261538 [PubMed - as supplied by publisher]

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Sep 282014
 

Review of Rapid Diagnostic Tests Used by Antimicrobial Stewardship Programs.

Clin Infect Dis. 2014 Oct 15;59(suppl 3):S134-S145

Authors: Bauer KA, Perez KK, Forrest GN, Goff DA

Abstract
Rapid microbiologic tests provide opportunities for antimicrobial stewardship programs to improve antimicrobial use and clinical and economic outcomes. Standard techniques for identification of organisms require at least 48-72 hours for final results, compared with rapid diagnostic tests that provide final organism identification within hours of growth. Importantly, rapid microbiologic tests are considered "game changers" and represent a significant advancement in the management of infectious diseases. This review focuses on currently available rapid diagnostic tests and, importantly, the impact of rapid testing in combination with antimicrobial stewardship on patient outcomes.

PMID: 25261540 [PubMed - as supplied by publisher]

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Sep 262014
 
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Pneumonia prevention to decrease mortality in intensive care unit. A systematic review and meta-analysis.

Clin Infect Dis. 2014 Sep 24;

Authors: Roquilly A, Marret E, Abraham E, Asehnoune K

Abstract
BACKGROUND:  The objective was to determine the strategies of prevention of hospital acquired pneumonia (HAP) that reduce mortality in intensive care unit (ICU).
METHODS:  Preferred Reported Items for Systemic Reviews and Meta-Analysis guidelines were followed. We searched the MEDLINE and COCHRANE controlled trials register (through June, 10(th) 2014) as well as reference lists of articles. We included all randomized controlled trials conducted in critically ill adult patients hospitalized in ICU and evaluating digestive prophylactic methods (selective digestive decontamination (SDD), acidification of gastric content, early enteral feeding, prevention of micro-inhalation); circuit prophylactic methods (closed suctioning systems, early tracheotomy, aerosolised antibiotics, humidification, lung secretion drainage, silver coated endotracheal tubes) or oro-pharyngeal prophylactic methods (selective oropharyngeal decontamination, patient position, sinusitis prophylaxis, subglottic secretion drainage, tracheal cuff monitoring). One reviewer extracted data that were checked by 3 others. The primary outcome was the mortality rate in ICU.
RESULTS:  We identified 157 randomized trials to pool in a meta-analysis. The primary outcome was available in 145 studies (n=37156). The risk ratio (RR) for death was 0.95 (95% confidence interval (CI), 0.92-0.99; p=0.02) in the intervention groups. In sub-group analysis, only SDD significantly decreased mortality as compared to control (n=10227; RR, 0.84; 95%CI, 0.76-0.92; p=0.0003). The RR for in-ICU death was 0.78 (CI95%, 0.69-0.89; p=0.0001, I(2)=33%) in trials investigating SDD with systemic antimicrobial therapy and 1.00 (CI95%, 0.84-1.21; p=0.96; I(2)=0%) without systemic antimicrobial therapy.
CONCLUSIONS:  SDD with systemic antimicrobial therapy reduced mortality and should be considered in critically ill patients at high risk for death.

PMID: 25252684 [PubMed - as supplied by publisher]

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