Jan 182015
Related Articles

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

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]

Link to Article at PubMed


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

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
Related Articles

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

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

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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Nov 282014

Staphylococcus aureus Skin Infection Recurrences among Household Members: An Examination of Host, Behavioral, and Pathogen Level Predictors.

Clin Infect Dis. 2014 Nov 26;

Authors: Miller LG, Eells SJ, David MZ, Ortiz N, Taylor AR, Kumar N, Cruz D, Boyle-Vavra S, Daum RS

BACKGROUND:  Many patients suffer from recurrent Staphylococcus aureus infections, but there are few data examining recurrence predictors.
METHODS:  We followed adults and children after treatment for S. aureus skin infections and their household contacts in Los Angeles and Chicago. We surveyed subjects for S. aureus body colonization, household fomite contamination, and behavioral and clinical factors at baseline and 3 and 6 months later. Using repeated measures modeling, we examined host, pathogen, behavior, and clinical factors associated with recurrence.
RESULTS:  Among 330 index subjects, 182 (55%) were infected with an isolate of the USA300 MRSA genetic background. Recurrences occurred in 39% by month 3 and 51% by month 6. Among 588 household contacts, 10% reported a skin infection by month 3 and 13% by month 6. Among index subjects, recurrence was associated with (P <0.05) Los Angeles site, diabetes, recent hospitalization, recent skin infection, recent cephalexin use, household S. aureus or MRSA fomite contamination; recurrence was inversely associated with recent contact sports participation. In the multivariate model, independent predictors of recurrence in index patients were recent hospitalization, household MRSA fomite contamination, and lack of recent contact sports participation. Among household contacts, independent predictors of subsequent skin infection were Chicago site, antibiotic use in the prior year, and skin infection in the prior 3 months.
CONCLUSIONS:  In our longitudinal study, patients with a S. aureus skin infection were more likely to suffer a recurrence if household fomites were MRSA contaminated. Interventions to prevent recurrence may be enhanced by decontamination of household fomites.

PMID: 25428411 [PubMed - as supplied by publisher]

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Nov 202014

Examining the Risks of Cardiac Arrhythmia and Mortality among New-Generation Macrolides, Fluoroquinolones, and Beta-Lactam/Beta-Lactamase Inhibitor: A Nationwide Study.

Clin Infect Dis. 2014 Nov 18;

Authors: Chou HW, Wang JL, Chang CH, Lai CL, Lai MS, Chan KA

BACKGROUND:  Previous studies have demonstrated increased cardiovascular mortality related to azithromycin and levofloxacin. Risks associated with alternative drugs in the same class, including clarithromycin and moxifloxacin, were unknown. We used the Taiwan National Health Insurance Database to perform a nationwide, population-based study that compares the risks of ventricular arrhythmia and cardiovascular death among these antibiotics.
METHOD:  A total of 10,684,100 patients prescribed oral azithromycin, clarithromycin, moxifloxacin, levofloxacin, ciprofloxacin, or amoxicillin/clavulanate at outpatient visit between January 2001 and November 2011. A logistic regression model adjusted for propensity score was used to calculate the odds ratios (ORs) and 95% confidence intervals (95% CIs) for adverse cardiac outcomes occurring within 7 days after the initiation of antibiotic treatment.
RESULT:  Compared with amoxicillin-clavulanate treatment, the use of azithromycin and moxifloxacin were associated with significant increases in the risks of ventricular arrhythmia and cardiovascular death. The adjusted ORs (95% CI) for ventricular arrhythmia were 4.32 (2.95-6.33) for azithromycin, 3.30 (2.07-5.25) for moxifloxacin, and 1.41 (0.91-2.18) for levofloxacin. For cardiovascular death, the adjusted ORs (95% CI) for azithromycin, moxifloxacin, and levofloxacin were 2.62 (1.69-4.06), 2.31 (1.39-3.84), and 1.77 (1.22-2.59), respectively. No association was noted between clarithromycin or ciprofloxacin and adverse cardiac outcomes.
CONCLUSION:  Healthcare professionals should consider the small but significant increased risk of ventricular arrhythmia and cardiovascular death when prescribing azithromycin and moxifloxacin. Additional research is needed to determine whether the increased risk of mortality is caused by the drugs, or related to the severity of infection or the pathogens themselves.

PMID: 25409476 [PubMed - as supplied by publisher]

Link to Article at PubMed