Feb 112015
 
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Adult Bacterial Meningitis: Earlier Treatment and Improved Outcome Following Guideline Revision Promoting Prompt Lumbar Puncture.

Clin Infect Dis. 2015 Feb 5;

Authors: Glimåker M, Johansson B, Grindborg Ö, Bottai M, Lindquist L, Sjölin J

Abstract
BACKGROUND:  In suspected acute bacterial meningitis (ABM), cerebral computerized tomography (CT) is recommended before lumbar puncture (LP) if mental impairment. Despite guideline emphasis on early treatment, performing CT prior to LP implies a risk of delayed treatment and unfavorable outcome. Therefore, Swedish guidelines were revised in 2009, deleting impaired mental status as a contraindication for LP without prior CT scan. The aim of the present study was to evaluate the guideline revision.
METHODS:  The Swedish quality registry for community-acquired ABM was analyzed retrospectively. Door-to-antibiotic time and outcome were compared among patients treated 2005-2009 (n = 394) and 2010-2012 (n = 318). The effect of different LP-CT sequences was analyzed during 2008-2012.
RESULTS:  Adequate treatment was started 1.2 hours earlier, and significantly more patients were treated <2 hours from admission 2010-2012 than 2005-2009. Compared with CT before LP, immediate LP resulted in 1.6 hours earlier treatment, significant increase in door-to-antibiotic times of <1 and <2 hours, and a favorable outcome. In 2010-2012, mortality was lower (6.9% vs 11.7%) and the risk of sequelae at follow-up decreased (38% vs 49%) in comparison with 2005-2009. Treatment delay resulted in a significantly increased risk for fatal outcome, with a relative increase in mortality of 12.6% per hour of delay.
CONCLUSIONS:  The deletion of impaired mental status as contraindication for prompt LP and LP without prior CT scan are associated with significantly earlier treatment and a favorable outcome. A revision of current international guidelines should be considered.

PMID: 25663160 [PubMed - as supplied by publisher]

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Jan 302015
 
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Colistin-Resistant Acinetobacter baumannii: Beyond Carbapenem Resistance.

Clin Infect Dis. 2015 Jan 28;

Authors: Qureshi ZA, Hittle LE, O'Hara JA, Rivera JI, Syed A, Shields RK, Pasculle AW, Ernst RK, Doi Y

Abstract
BACKGROUND:  With an increase in the use of colistin methansulfonate (CMS) to treat carbapenem-resistant A. baumannii infections, colistin resistance is emerging.
METHODS:  Patients with infection or colonization due to colistin-resistant A. baumannii were identified at a hospital system in Pennsylvania. Clinical data were collected from electronic medical records. Susceptibility testing, pulsed-field gel electrophoresis (PFGE), and multilocus sequence typing (MLST) were performed. To investigate mechanism of colistin resistance, lipid A was subjected to matrix-assisted laser desorption mass spectrometry.
RESULTS:  Twenty patients with colistin-resistant A. baumannii were identified. Ventilator-associated pneumonia was the most common type of infection. Nineteen patients had received intravenous and/or inhaled CMS for treatment of carbapenem-resistant, colistin-susceptible A. baumannii infection prior to identification of colistin-resistant isolates. The 30-day all-cause mortality rate was 30%. The treatment regimen for colistin-resistant A. baumannii infection associated with the lowest mortality rate was combination of CMS, a carbapenem and ampicillin-sulbactam. The colistin-susceptible and resistant isolates from the same patients were highly related by PFGE, but isolates from different patients were not, suggesting evolution of resistance during CMS therapy. By MLST, all isolates belonged to the International Clone 2, the lineage that is epidemic worldwide. Phosphoethanolamine modification of lipid A was present in all colistin-resistant A. baumannii isolates.
CONCLUSIONS:  Colistin-resistant A. baumannii occurred almost exclusively among patients who had received CMS for treatment of carbapenem-resistant, colistin-susceptible A. baumannii infection. Lipid A modification by the addition of phosphoethanolamine accounted for colistin resistance. Susceptibility testing for colistin should be considered for A. baumannii identified from CMS-experienced patients.

PMID: 25632010 [PubMed - as supplied by publisher]

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Jan 182015
 
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Point-of-Prescription Interventions to Improve Antimicrobial Stewardship.

Clin Infect Dis. 2015 Jan 16;

Authors: Hamilton KW, Gerber JS, Moehring R, Anderson DJ, Calderwood MS, Han JH, Mehta JM, Pollack LA, Zaoutis T, Srinivasan A, Camins BC, Schwartz DN, Lautenbach E, for the CDC Prevention Epicenters Program

Abstract
Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. While antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such "top-down" methods as formulary restriction and prospective audit with feedback, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship.

PMID: 25595748 [PubMed - as supplied by publisher]

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Jan 152015
 

Carbapenem Therapy is Associated with Improved Survival Compared to Piperacillin-Tazobactam for Patients with ESBL Bacteremia.

Clin Infect Dis. 2015 Jan 13;

Authors: Tamma PD, Han JH, Rock C, Harris AD, Lautenbach E, Hsu AJ, Avdic E, Cosgrove SE, for the Antibacterial Resistance Leadership Group

Abstract
BACKGROUND:  The effectiveness of piperacillin-tazobactam (PTZ) for the treatment of ESBL bacteremia is controversial. We compared 14-day mortality of PTZ vs. carbapenems as empiric therapy in a cohort of patients with ESBL bacteremia who all received definitive therapy with a carbapenem.
METHODS:  Patients hospitalized between January 2007 and April 2014 with monomicrobial ESBL bacteremia were included. A decrease of >3 doubling dilutions in the minimum inhibitory concentration for third-generation cephalosporins tested in combination with 4 µg/ml of clavulanic acid was used to confirm ESBL status. The primary exposure was empiric therapy, defined as antibiotic therapy administered to a patient before ESBL status was known. Patients were excluded if they did not receive a carbapenem after ESBL production was identified. The primary outcome was time to death from the first day of bacteremia. Propensity scores using inverse probability of exposure weighting (IPW) were used to estimate the probability that a patient would receive PTZ versus carbapenems empirically. We calculated overall hazard ratios for mortality censored at 14 days using Cox proportional-hazards models on an IPW-adjusted cohort.
RESULTS:  A total of 331 unique patients with ESBL bacteremia were identified. One-hundred and three (48%) patients received PTZ empirically and 110 (52%) received carbapenems empirically. The adjusted risk of death was 1.92 times higher for patients receiving empiric PTZ compared with empiric carbapenem therapy (95% CI, 1.07-3.45).
CONCLUSIONS:  PTZ appears inferior to carbapenems for the treatment of ESBL bacteremia. For patients at high risk of invasive ESBL infections, early carbapenem therapy should be considered. Our findings should not be extended to beta-lactam/beta-lactamase inhibitor combinations in development as limited clinical data are available for these agents.

PMID: 25586681 [PubMed - as supplied by publisher]

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Dec 052014
 
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Potential Role for Telavancin in Bacteremic Infections Due to Gram-Positive Pathogens: Focus on Staphylococcus aureus.

Clin Infect Dis. 2014 Dec 3;

Authors: Corey GR, Rubinstein E, Stryjewski ME, Bassetti M, Barriere SL

Abstract
Staphylococcus aureus bacteremia (SAB) is one of the most common serious bacterial infections and the most frequent invasive infection due to methicillin-resistant S. aureus (MRSA). Treatment of SAB is challenging, with metastatic and relapsing infections commonplace, and is particularly difficult in patients with MRSA owing to limited treatment options. Telavancin is a bactericidal lipoglycopeptide antibiotic that is active against a range of clinically relevant Gram-positive pathogens, including MRSA. In experimental animal models of sepsis, using human exposures, telavancin has been shown to be more effective than vancomycin. In clinically evaluable patients enrolled in a pilot study of uncomplicated SAB, cure rates were 88% for telavancin and 89% for standard therapy. Among patients with infection due to only Gram-positive pathogens enrolled in the two phase 3 studies of telavancin for treatment of hospital-acquired pneumonia, cure rates for those with bacteremic S. aureus pneumonia were 41% (9/22, telavancin) and 40% (10/25, vancomycin) with identical mortality rates. These data support further evaluation of telavancin in larger, prospective studies of SAB.

PMID: 25472944 [PubMed - as supplied by publisher]

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Dec 032014
 

Clinical Presentation and Risk Factors for Cytomegalovirus Colitis in Immunocompetent Adult Patients.

Clin Infect Dis. 2014 Dec 1;

Authors: Ko JH, Peck KR, Lee WJ, Lee JY, Cho SY, Ha YE, Kang CI, Chung DR, Kim YH, Lee NY, Kim KM, Song JH

Abstract
BACKGROUND:  Cytomegalovirus (CMV) colitis is a common manifestation of CMV end-organ disease, which has typically been described in immunocompromised hosts. Recently, it has been noted that this also occurs in immunocompetent patients. To gather relevant data about clinical presentation, prognosis, and risk factors for development of CMV colitis in immunocompetent hosts, we analyzed all cases that occurred during a 19 year period at our institution.
METHODS:  A case-control study was performed to identify risk factors for CMV colitis in immunocompetent hosts. Electronic medical records of individuals who were admitted and diagnosed with CMV colitis between January 1995 and February 2014 at a tertiary care university hospital were reviewed. Two non-CMV colitis patients that were age- and sex-matched were selected as controls for each case.
RESULTS:  A total of 51 patients with CMV colitis were included in this study along with 102 control patients. Certain conditions including renal disease on hemodialysis, neurologic disease, rheumatologic disease, required ICU care, and exposure to antibiotics, antacids, steroids, or RBC transfusions within 1 month of diagnosis of colitis were associated with CMV colitis on univariate analysis. Among these, steroid use and RBC transfusion within 1 month were identified as independent risk factors for developing CMV colitis on multivariate analysis. The 30-day mortality rate was 7.8% without any attributable mortality.
CONCLUSIONS:  Steroid use and RBC transfusion within 1 month of the diagnosis of colitis were independent risk factors for development of CMV colitis in immunocompetent hosts.

PMID: 25452594 [PubMed - as supplied by publisher]

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