The impact of the multidisciplinary Endocarditis Team on the management of infective endocarditis.

BACKGROUND: In their latest guidelines for infective endocarditis (IE) (2015), the European Society of Cardiology (ESC) introduced the implementation of the Endocarditis Team (ET) to facilitate the management of IE. This study presents our experiences and the diagnostic and therapeutic impact of the ET on the management of IE. METHODS: From 2016-2020, data of all patients with suspected IE referred to the ET were prospectively collected. The final diagnosis was defined by the ET as either rejected, possible or definite IE. Diagnostic impact was scored as any change in initial diagnosis, the frequency of additional diagnostic tests advised by the ET and any change in diagnosis after these tests. Therapeutic impact was scored as any change in antibiotic therapy or change from conservative to invasive therapy or vice versa. RESULTS: A total of 321 patients (median age 67 [55-77] years, 71% male) were enrolled. The final diagnosis was rejected IE in 47 (15%), possible IE in 34 (11%) and definite IE in 240 (75%) patients. A change of initial diagnosis was seen in 53/321(17%) patients. Additional microbiological tests were advised in 69/321 (21%) patients, and additional imaging tests in 136/321 (42%) patients, which resulted in subsequent change in diagnosis in 23/321 (7%) patients. Any change in antibiotic treatment was advised in 135/321 (42%) patients, and change from initial conservative to additional surgical treatment in 15/321 (5%) patients. CONCLUSION: The ET had a clear impact on the therapeutic policy for patients with suspected IE and is useful in the management of this life-threatening disease. Broad implementation is warranted.

Point prevalence of appropriate antimicrobial therapy in a Dutch university hospital.

Antimicrobial stewardship teams have been shown to increase appropriate empirical antibiotic therapy and reduce medical errors and costs in targeted populations, but the effect in non-targeted populations is still unclear. The aim of this study was to determine the prevalence of inappropriate antibiotic use in a large university hospital and identify areas in which antimicrobial stewardship will be the most effective. In a point prevalence survey we assessed the appropriateness of antibiotic therapy using an electronic surveillance system in combination with a standardized method for duration of therapy, dosage, dosage interval, route of administration, and choice of antibiotic drug. Patients using at least one antibiotic drug were included. Among 996 patients admitted in the surveyed wards, 337 patients (33.8 %) used one or more antibiotic drugs. Two hundred and twenty-one patients (22.2 %) used antibiotic medication therapeutically, with a total of 307 antibiotic prescriptions. Antibiotic therapy was deemed inappropriate in 90 (29.3 %) of these prescribed antibiotics, with an unjustified prescription as the most common reason for an inappropriate prescription. Use of fluoroquinolones and amoxicillin/clavulanic acid and a presumed diagnosis of fever of unknown origin, urinary tract infection, and respiratory tract infection were associated with inappropriate antibiotic therapy. Our study provides insight into the (in)appropriateness of antibiotic prescriptions in a tertiary care center in the Netherlands and identifies areas for improvement. The use of an electronic surveillance system for this point prevalence study is easy and may serve as a baseline measurement for the future effect of antibiotic stewardship.

Infectious diseases and the use of antibiotics in outpatients at the emergency department of the University Hospital of León, Nicaragua.

BACKGROUND: In order to develop guidelines for the use of antimicrobial agents, it is necessary to obtain detailed information on the prevalence of infectious diseases and antibiotic usage. METHODS: A retrospective study was conducted among outpatients with acute infections visiting the emergency department of the University Hospital of León, Nicaragua. RESULTS: Over the course of one month, 2027 patients visited the emergency department. Seven hundred and thirty-two patients (36.1%) had an infection, with a total of 799 acute infections. The majority of patients (55.9%) were children. Respiratory tract infections (43.4%), urogenital infections (29.5%), and diarrhea or gastroenteritis of presumed infectious origin (8.8%) were the most frequent infections. Among respiratory tract infections, the most frequent diagnoses were community-acquired pneumonia (CAP; 31.4%), acute tonsillitis (28.2%), and the common cold (17.6%). CAP was treated with procaine benzylpenicillin in 70.6% of cases, whereas 84.0% of patients with acute tonsillitis were treated with a single dosage of benzathine benzylpenicillin intramuscularly. Among urogenital infections, the most frequent diagnosis was acute uncomplicated urinary tract infection (24.2%). Approximately a quarter of patients with uncomplicated urinary tract infections did not receive treatment according to the local guidelines. Of the patients with acute diarrhea, 27.1% were treated with antibiotics, while only a minority had leukocytes in Wright stain of the feces. CONCLUSIONS: In conclusion our study shows that the use of antimicrobial agents is not optimal. Antibiotics were prescribed too often and not according to the local guidelines. This will further exacerbate the resistance problem in Nicaragua.

[Post-exposure prophylaxis following exposure to HIV: adaptation to the situation may be indicated]. / Postexpositieprofylaxe na blootstelling aan HIV: aanpassing aan de situatie kan geïndiceerd zijn.

A woman aged 36 injured herself on a needle that had been used to take an iliac-crest biopsy from an HIV-positive patient and a man aged 34 and a woman aged 35 had sexual contact with their HIV-positive partners during which the condom tore. They were given post-exposure prophylaxis (PEP) which was formulated using medication and virus resistance data from the HIV-positive individual. At 3 and 6 months the patients were all still HIV-negative. After occupational or non-occupational exposure to HIV, PEP is initiated if there is a reasonable risk of transmission of HIV. In The Netherlands a combination of 3 antiretroviral drugs is advised based on demonstrated antiviral effectiveness in the regular treatment of HIV-infections. Frequently a standard PEP-regimen is prescribed. If the source patient has a history of antiretroviral therapy, the virus might be resistant to standard PEP-regimens. In these cases the choice of drugs in the PEP-regimen can be individualised based on the antiretroviral medication history of the source patient and known resistance patterns of the source virus.

Computer-assisted decision support for the diagnosis and treatment of infectious diseases in intensive care units.

Diagnosing nosocomial infections in critically ill patients admitted to intensive care units (ICUs) is a challenge because signs and symptoms are usually non-specific for a particular infection. In addition, the choice of treatment, or the decision not to treat, can be difficult. Models and computer-based decision-support systems have been developed to assist ICU physicians in the management of infectious diseases. We discuss the historical development, possibilities, and limitations of various computer-based decision-support models for infectious diseases, with special emphasis on Bayesian approaches. Although Bayesian decision-support systems are potentially useful for medical decision making in infectious disease management, clinical experience with them is limited and prospective evaluation is needed to determine whether their use can improve the quality of patient care.

Resistance of uropathogens in symptomatic urinary tract infections in León, Nicaragua.

Management of urinary tract infections (UTI) in Central America and especially Nicaragua, is complicated by the lack of knowledge about the antibiotic resistance of uropathogens. We conducted a prevalence study to gain more insight into the aetiology, bacterial resistance and risk factors for symptomatic UTI in the region of León, Nicaragua. In 2002, all consecutive patients with UTI symptoms and pyuria >/=10 WBC/hpf were admitted to the study. Positive cultures from midstream urine specimens were defined as >/=10(5) cfu/ml of a single uropathogen. Susceptibility tests were performed with disc diffusion tests using the Kirby-Bauer method and broth microdilution using National Committee for Clinical Laboratory Standards criteria both in León and a reference laboratory in Utrecht. A positive culture was present in 62 of 208 study subjects (30%). Escherichia coli (56%), Klebsiella spp. (18%) and Enterobacter spp. (11%) were the most frequent pathogens isolated. Presence of cystocele, incontinence and increasing age were risk factors for bacterial UTI. E. coli was least resistant to ceftriaxone, amikacin and nitrofurantoin (>90% susceptible). We observed high resistance rates in E. coli to amoxicillin (82%, MIC(90) 128 mg/l), trimethoprim-sulphamethoxazole (TMP-SMX) (64%, MIC(90) 32 mg/l), cephalothin (58%, MIC(90), 32 mg/l), ciprofloxacin (30%; MIC(90), 32 mg/l), amoxicillin/clavulanate (21%, MIC(90) 8 mg/l) and gentamicin (12%, MIC(90) 2 mg/l). Our results suggests that community acquired uropathogens in Nicaragua are highly resistant to many antimicrobial agents. The use of amoxicillin, trimethoprim-sulphamethoxazole and cephalothin against uropathogens needs to be reconsidered. High quinolone resistance rates among E. coli in Nicaragua gives cause for great concern.

Do cultures contribute to optimisation of antibiotic therapy in the intensive care unit?

Obtaining diagnostic microbiological cultures before initiating empirical antimicrobial therapy is part of the diagnostic work-up of intensive care patients with a clinical suspicion of infection. However, it is unknown to what extent these cultures provide a microbiological cause of infection and to what extent antimicrobial therapy is influenced. During a 6-month period, all episodes of suspected clinical infection were analysed and categorised as non-microbiologically proven infection (non-MPI) or MPI. Effects of culture results on antibiotic therapy were analysed for episodes of respiratory tract infection. Invasive diagnostic techniques were not routinely used for diagnosis of respiratory tract infections. Among 212 patients admitted, 147 episodes of clinical suspicion of infection were recorded (104 for respiratory tract infection) and 1147 microbiological cultures were obtained (0.64 culture per patient day). Antibiotics were administered on 1111 (62%) of 1803 patients days. Of the respiratory tract infections, 571 cultures resulted in 49 (47%) MPI. Cover with empirical antibiotics was inappropriate in 7 of 104 cases (8%) of respiratory infections. In 12 cases (11.5%) empirical therapy could have been changed based on culture results. Negative cultures were never followed by cessation of therapy, but the duration of treatment was significantly shorter for non-MPI. Forty-seven percent of respiratory tract infections were microbiologically confirmed and, based on culture results, empirical antimicrobial therapy could have been influenced in 11.5% of cases of respiratory tract infections. These findings provide aspects to evaluate and improve the diagnostic work-up of infections in the ICU.

Double-blind, placebo-controlled study comparing the effect of azithromycin with clarithromycin on oropharyngeal and bowel microflora in volunteers.

The purpose of this double-blind study was to assess the effect of azithromycin and clarithromycin on oral and fecal microflora. Bacterial species from fecal samples and throat washes from healthy volunteers were identified and quantified before, during and after receipt of either placebo ( n=6), azithromycin (500 mg once daily for 3 days; n=6) or clarithromycin (500 mg twice daily for 7 days; n=6). In both antibiotic groups, the changes in oropharyngeal aerobic microflora following antibiotic administration were minor. Antibiotics neither changed the bacterial load of Streptococcus spp. compared with placebo, nor did macrolide-resistant streptococci emerge. In the fecal aerobic microflora, the number of organisms of the family Enterobacteriaceae decreased slightly after antibiotic administration in both the clarithromycin and the azithromycin groups, but levels normalized by day 21 after therapy. No colonization with nonfermenters or Clostridium difficile was seen, and the total number of anaerobic bacteria was not affected in any study group. In conclusion, there were no significant differences between azithromycin and clarithromycin in their effect on human oropharyngeal and intestinal microflora, nor was the use of these antibiotics associated with colonization by resistant, gram-positive organisms or overgrowth of opportunistic microorganisms.