Effects of flexible scheduling and virtual visits on burnout for clinicians.

OBJECTIVE: Burnout is a healthcare quality problem, linked to negative impacts in patient care and healthcare providers. The pandemic prompted clinicians to adapt virtual practices and adopt more flexible, autonomous schedules. However, the impact of flexible scheduling and autonomy on provider burnout is unknown. The study aim was to evaluate the effect of flexible schedules versus standard schedules, and the amount of digital care, on burnout. METHODS: This was a prospective survey study at two time points 6 months apart. Providers from Rheumatology, Neurology, and Pediatrics completed surveys at baseline, between 6/22/2020-9/8/2020, and six months later, between 12/20/20-3/12/21. The primary outcome was the Mini-Z work life survey which measured burnout in 2 different groups: flexible schedules (FS) and standard schedules (SS) during the height of the pandemic. RESULTS: The study included 149 providers, 47 with FS and 102 with SS, who completed the survey at baseline and 6 months later. At baseline providers reported high job satisfaction (85.9%) and low burnout (29.7%), which remained consistent at 6 months. Compared to those with SS, clinicians with FS participated in a greater number of telemedicine activities at baseline, but did not differ significantly in degree of burnout (25.5% FS, 31.7% SS, p=0.45). Participants in the FS group were significantly more likely to indicate improvement in control over workload and experience reduced work-related stress compared to those in the SS group. There was no association between amount of telemedicine visits and burnout. Predictors of burnout at 6 months included Rheumatology providers and those in the 20-39 year old age group. DISCUSSION: Schedule flexibility does not appear to influence overall burnout; however it does impact variables associated with burnout such as control over workload and perceived job stress. CONCLUSIONS: Participants reported overall job satisfaction, and FS did not impact overall burnout. FS was more likely to indicate improvement in control over workload and experienced reduced work-related stress compared to SS. In addition, burnout was more likely in the 20-39 year old age group, suggesting that special focus should be paid to this age group.

Propionibacterium acnes endocarditis: a case series.

OBJECTIVES: Propionibacterium acnes remains a rare cause of infective endocarditis (IE). It is challenging to diagnose due to the organism's fastidious nature and the indolent presentation of the disease. The purpose of this study was to describe the clinical presentation and management of P. acnes IE with an emphasis on the methods of diagnosis. METHODS: We identified patients from the Cleveland Clinic Infective Endocarditis Registry who were admitted from 2007 to 2015 with definite IE by Duke Criteria. Propionibacterium acnes was defined as the causative pathogen if it was identified in at least two culture specimens, or identified with at least two different modalities: blood culture, valve culture, valve sequencing or histopathological demonstration of microorganisms. RESULTS: We identified 24 cases of P. acnes IE, 23 (96%) of which were either prosthetic valve endocarditis or IE on an annuloplasty ring. Invasive disease (71%) and embolic complications (29%) were common. All but one patient underwent surgery. Propionibacterium acnes was identified in 12.5% of routine blood cultures, 75% of blood cultures with extended incubation, 55% of valve cultures, and 95% of valve sequencing specimens. In 11 of 24 patients (46%), no causative pathogen would have been identified without valve sequencing. CONCLUSIONS: Propionibacterium acnes almost exclusively causes prosthetic valve endocarditis and patients often present with advanced disease. The organism may not be readily cultured, and extended cultures appear to be necessary. In patients who have undergone surgery, valve sequencing is most reliable in establishing the diagnosis.

Outcomes with daptomycin versus standard therapy for osteoarticular infections associated with Staphylococcus aureus bacteraemia.

OBJECTIVES: To evaluate the clinical characteristics, treatment and outcomes of patients with osteoarticular infections (OAIs) associated with Staphylococcus aureus bacteraemia (SAB). METHODS: The clinical characteristics and outcomes for patients with OAI were described using a post hoc analysis of an open label, randomized trial comparing daptomycin with standard therapy (vancomycin or anti-staphylococcal penicillin with initial gentamicin) for the treatment of SAB. RESULTS: OAI occurred in 32 of 121 patients (21 daptomycin and 11 standard therapy) with complicated SAB (18 septic arthritis, 9 vertebral osteomyelitis and 7 others). Two patients had osteomyelitis in more than one site. Success rates seen in two groups were as follows: vertebral osteomyelitis [3/5 (60%) daptomycin versus 0/2 (0%) comparator], septic arthritis [7/11 (64%) versus 3/5 (60%)], sternal osteomyelitis [3/3 (100%) versus 1/2 (50%)] and long bone osteomyelitis [0/1 (0%) versus 1/1 (100%)]. Success rates in both treatment groups improved with surgical therapy. Creatine phosphokinase elevations to >500 IU/L occurred in one patient on daptomycin who discontinued therapy, whereas renal impairment developed in three patients on standard therapy, two of whom discontinued therapy. Two patients treated with daptomycin and one patient on vancomycin had increases in S. aureus MICs to daptomycin and vancomycin, respectively. Three patients treated with daptomycin died following completion of therapy, with mortality attributed to multiple co-morbid conditions and inadequate debridement of OAIs in these patients. No deaths were reported in the standard therapy group. CONCLUSIONS: Daptomycin may be considered an alternative to standard therapy in the treatment of patients with complicated SAB and OAI.

Protease-sparing regimen in a real-life practice with naïve patients: an equal opportunity approach?

PURPOSE: Proven clinical efficacy of protease-sparing regimens (PSR) has been shown. Concerns exist about broad applicability of these regimens in advanced naïve patients. Recent reports have associated a rise in liver enzymes with nevi rapine; however, no data exist with efavirenz. METHOD: 17 consecutive antiretroviral-naïve HIV patients were started on a PSR with efavirenz plus two nucleoside reverse transcriptase inhibitors. Baseline liver enzymes, serum CD38, CD4, and HIV viral load data were collected. Correlation between change in viral load and immune reconstitution on therapy were compared to baseline laboratory values. RESULTS: All patients had a mean viral load decrease of >2 logs, including patients with low initial CD4% or high viral load, and there was no increase of liver enzymes observed at a median follow-up of 42 weeks (range 17-78). There was a perfect correlation between the change in viral load and the initial viral load (p <.0001, r = 1.00) including patients with viral load > or =100,000 copies/mL and CD4 count< or =50 (n = 5). Even patients with low initial CD4 had a significant percentage increase in CD4 count (p <.0002, r = 0.7880). CD38% showed a positive correlation with change in viral load (p =.046, r = 0.522). CONCLUSION: All patients experienced a mean viral load decrease of >2 logs (88% less than 400 copies/mL and 35% less than 20 copies/mL). There were no observed increases in liver enzymes. Patients with low CD4 counts, high initial viral load, or high CD38 expression still experienced a significant change in viral load.

Treatment of vancomycin-resistant Enterococcus faecium infections with quinupristin/dalfopristin.

Clinicians caring for patients with vancomycin-resistant Enterococcus faecium (VREF) infections face severe constraints in the selection of treatment. Quinupristin/dalfopristin (Synercid) is active in vitro against VREF, with a MIC(90) of 1.0 microg/mL. We investigated the clinical efficacy and safety of this agent in a multicenter, prospective, noncomparative, emergency-use study of 396 patients. Patients were included if they had signs and symptoms of active infection, including bacteremia of unknown origin, intra-abdominal infection, and skin and skin-structure infection, with no alternative antibiotic therapy available. The mean duration of treatment was 20 days (range, 4-40 days). The clinical response rate was 68.8% in the evaluable subset, and the overall response rate was 65.6%. The most common adverse events related to quinupristin/dalfopristin were arthralgias and myalgias. Related laboratory abnormalities were rare. In this severely ill patient population, quinupristin/dalfopristin was efficacious and demonstrated an acceptable safety profile in the treatment of VREF infection.

Successful administration of quinupristin/dalfopristin in the outpatient setting.

Intravenous administration of quinupristin/dalfopristin outside the hospital setting has not been reported previously. We describe 37 outpatients receiving quinupristin/dalfopristin iv for infections including osteomyelitis, bacteraemia, abscesses and cellulitis. The most frequent aetiological pathogens found were Enterococcus faecium, Staphylococcus aureus and coagulase-negative staphylococci. Patients received an average of 9 days therapy as inpatients and 22 days as outpatients. Quinupristin/dalfopristin was administered using various access devices, most commonly peripherally inserted central catheters and tunnelled central catheters. The bacteriological and clinical success rates were both 89.2%. Five patients were readmitted to hospital; one patient developed catheter-related bacteraemia. The most frequently reported non-venous adverse events were nausea (18.9% of patients), myalgia (18.9%) and arthralgia (13.5%). Sixteen patients experienced venous access-related events, most commonly infusion pain, oedema and phlebitis. In this group of patients, for those who had difficult-to-treat infections, intravenous quinupristin/dalfopristin therapy was generally effective and safe outside the hospital setting.

Outpatient intravenous antibiotic therapy for endocarditis.

The clinical spectrum of endocarditis continues to evolve, as does its diagnosis and management. Outpatient parenteral antimicrobial therapy has been demonstrated to be safe and effective for medically stable patients with viridans streptococcal endocarditis. Other carefully selected and monitored patients with infective endocarditis may also be considered for completion of therapy outside the hospital setting.

Practice guidelines for community-based parenteral anti-infective therapy. ISDA Practice Guidelines Committee.

This is the fourth in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of this guideline is to provide assistance to clinicians when making decisions on when and how to best administer parenteral antimicrobial therapy. The targeted providers are internists, pediatricians, family practitioners, and other providers of outpatient antiinfective therapy. Criteria for selecting the appropriate patients and settings to deliver therapy in the community are described. Panel members represented experts in adult and pediatric infectious diseases. The guidelines are evidence-based. A standard ranking system is used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary and tables highlight the major recommendations.

Sternotomy infection with Mycoplasma hominis: a cause of "culture negative" wound infection.

Wound infections with Mycoplasma species are unusual; diagnosis may be delayed because of the growth characteristics of this organism. We report Mycoplasma hominis infection of sternotomy wounds in two patients. The first presented with fever and drainage from the incision 1 week after coronary artery bypass grafting. The other patient presented with drainage from the incision three weeks after double-lung transplantation. In both cases, initial cultures were negative, but the typical colonial morphology of M. hominis was subsequently detected. Successful treatment consisted of debridement and long courses of antibiotic therapy; omental flap grafting was eventually required for the second patient. Other published cases were reviewed and compared with the newly reported cases.

Left ventricular to right atrial fistula after aortic homograft replacement for endocarditis.

The treatment is described of a patient who had severe bacterial endocarditis with aortic valve destruction and septal abscess complicated by left ventricular to right atrial fistula 3 months after aortic homograft root replacement and septal debridement and repair. The status of the aortic homograft and anatomy of the fistula were defined precisely by echocardiography, making successful repair through a right atriotomy possible without disturbing the aortic homograft and the implanted coronary arteries.

Vertebral osteomyelitis and aortic lesions: case report and review.

Coexistence of vertebral osteomyelitis and lesions of the aorta is rare but may be lethal if not diagnosed promptly and treated effectively. We describe a patient who was treated at the Cleveland Clinic Hospital, and we review 69 additional cases reported in the literature. The native aorta was involved in 66 cases; four patients developed infection of prosthetic aortic grafts. The most common aortic lesions associated with vertebral osteomyelitis were mycotic aneurysms, infected aneurysms, and pseudoaneurysms. The wide variety of pathogens involved included salmonellae and other gram-negative bacilli, mycobacteria, gram-positive cocci, and fungi. In some cases infection was polymicrobial. The condition was associated with protean clinical manifestations. Diagnosis was frequently delayed, and mortality was 71%. In some instances surgical procedures at sites of unsuspected aneurysms precipitated life-threatening hemorrhage. Therapy with antimicrobial drugs alone was insufficient. The best results were achieved when specific drug therapy was combined with resection of the infected aorta or aortic graft, thorough debridement, and extraanatomic bypass grafting.

Hospital utilization for AIDS: are all hospital days necessary?

This study examined hospital utilization and, specifically, unnecessary hospital days for patients with acquired immunodeficiency syndrome (AIDS) in a Midwest regional referral center as of June 1987. In 1990 a follow-up study was conducted to measure changes in length of stay (LOS) and unnecessary days. Results show a mean LOS consistent with other studies and a pattern of unnecessary days comprising 14% to 18% respectively of the mean LOS. Admissions in which the patient died and those considered outliers (LOS greater than 36 days) had a trend toward a higher percentage of unnecessary days. Hospital utilization and unnecessary days for patients with AIDS should be an ongoing quality indicator for hospitals experiencing a high volume of persons with AIDS admissions.

Upper airway obstruction due to tonsillar lymphadenopathy in human immunodeficiency virus infection.

Head and neck manifestations of human immunodeficiency virus (HIV) infection are common and include diffuse cervical lymphadenopathy, cutaneous and mucosal Kaposi's sarcoma, mucosal herpes simplex infection, upper aerodigestivetractcandidiasis, and parotidlymphadenopathy and cysts. Recurrent otitis media and chronic sinusitis have been noted in the pediatric HIV population. We describe a patient with HIV-associated tonsillar and adenoid lymphadenopathy and upper airway obstruction. Pathologic analysis of the tonsillar tissue revealed severe lymphofollicular hyperplasia similar to that of other lymphoid tissue in HIV infection. The importance of symptomatic treatment of the airway obstruction is stressed.

Decreased infections in cardiac transplant recipients on cyclosporine with reduced corticosteroid use.

Fifty patients undergoing orthotopic cardiac transplantation were monitored over 34 months for evidence of infection. Four separate immunosuppressive protocols were used during the course of the study; the most recent protocol (protocol 4) employed significantly lower overall steroid dosages than the earlier protocols (protocols 1,2, and 3). All immunosuppressive regimens used cyclosporine, and azathioprine was added in the last three protocols. Statistical techniques to compare the occurrence of infection in protocols 1,2, and 3 v protocol 4 showed that patients in protocol group 4 (n = 21) had significantly more time free of pneumonia (P = .02) and major infections (P = .04) and marginally more time free of symptomatic cytomegalovirus infection (P = .08) than patients in protocol groups 1, 2, and 3 (n = 29). The median incidence of major infection per month was lower for protocol group 4 (P = .02). The time free of viral infection did not differ significantly between the two groups (P = .75) nor did the median incidence of rejection per month (P = .19). The authors conclude that reduction of steroid dosages in cardiac transplant patients receiving cyclosporine is associated with a significant decrease in the incidence of clinically important infections.

Infections of the cardiac suture line after left ventricular surgery.

PURPOSE: Infections of the cardiac suture line after left ventricular surgery are rare but may be fatal if not diagnosed promptly and treated effectively. In order to alert physicians to this entity, we reviewed data from three patients who presented at the Cleveland Clinic Hospital and from 22 patients in the literature. PATIENTS AND METHODS: The three patients in the current report underwent treatment at the Cleveland Clinic Hospital. Additional cases of infection of the left ventricular suture line were identified by reviewing the English literature pertaining to surgery for left ventricular aneurysms, pseudoaneurysms, and postoperative cardiac infections. RESULTS: Infection presented on average 16 months after surgery with cardiocutaneous fistulae, chest wall masses, hemoptysis or other pleuropulmonary symptoms, or systemic illness with bacteremia resembling endocarditis. Staphylococci and gram-negative bacilli were the most frequent pathogens. Diagnosis was often delayed and mortality was high. Left ventricular false aneurysms were identified in 15 of the 25 patients. Bleeding from sinuses in the chest wall or epigastrium or repeated hemoptysis were important clinical clues. In some instances, ill-advised surgical or instrumental procedures precipitated life-threatening hemorrhage. Treatment with antibiotics alone was insufficient. Excision of all infected sutures and Teflon pledgets and adequate debridement of the infected suture line were required to achieve cures. CONCLUSION: Since infection of the left ventricular suture line has protean clinical manifestations and may present months or years after the initial surgery, a high index of suspicion is of paramount importance in diagnosing the condition. Institution of cardiopulmonary bypass and reoperation through median sternotomy is recommended to achieve a cure.