Sepsis in Immunocompromised Patients Without Human Immunodeficiency Virus.

Sepsis remains among the most common complications from infectious diseases worldwide. The morbidity and mortality rates associated with sepsis range from 20% to 50%. The advances in care for patients with an immunocompromised status have been remarkable over the last 2 decades, but sepsis continues to be a major cause of death in this population Immunocompromised patients who are recipients of a solid organ or hematopoietic stem cell transplant are living longer with a better quality of life. However, some of these patients need lifelong treatment with immunosuppressive medications to maintain their transplant status. A consequence of the need for this permanent immunosuppression is the high risk of opportunistic, community, and hospital-acquired infections, all of which can lead to sepsis. In addition, the detection of serious infections may be more challenging owing to patients' lower ability to mount the clinical symptoms that usually accompany sepsis. This article provides an update on the current knowledge of sepsis in immunocompromised patients without human immunodeficiency virus. It reviews the most pertinent causes of sepsis in this population, and addresses the specific diagnostic and therapeutic challenges in neutropenia and solid organ and hematopoietic stem cell transplantation.

Impact of a syndrome-specific antibiotic stewardship intervention on antipseudomonal antibiotic use in inpatient diabetic foot infection management.

Objective: To demonstrate that a syndromic stewardship intervention can safely reduce antipseudomonal antibiotic use in the treatment of inpatient diabetic foot infections (DFIs). Intervention and method: From November 2017 through March 2018, we performed an antimicrobial stewardship intervention that included creation of a DFI best-practice guideline, implementation of an electronic medical record order set, and targeted education of key providers. We conducted a retrospective before-and-after study evaluating guideline adherent antipseudomonal antibiotic use 1 year before and after the intervention using interrupted time-series analysis. Setting: University of Nebraska Medical Center, a 718-bed academic medical center in Omaha, Nebraska. Patients: The study included 193 adults aged ≥19 years (105 in the preintervention group and 88 in the postintervention group) admitted to non-intensive care units whose primary reason for antibiotic treatment was diabetic foot infection (DFI). Results: Guideline-adherent use of antipseudomonal antibiotics increased from 39% before the intervention to 68% after the intervention (P ≤ .0001). Antipseudomonal antibiotic use decreased from 538 days of therapy (DOT) per 1,000 DFI patient days (PD) before the intervention to 272 DOT per 1,000 DFI PD after the intervention (P < .0001), with a statistically significant decrease in both level of use and slope of change. We did not detect any changes in length of stay, readmission, amputation rate, subsequent positive Clostridioides difficile testing, or mortality. Conclusions: Our 3-component intervention of guideline creation, implementation of an order set, and targeted education was associated with a significant decrease in antipseudomonal antibiotic use in the management of inpatient DFIs. DFIs are common and should be considered as opportunities for syndromic stewardship intervention.

Evaluation of cerebrospinal fluid white blood cell count criteria for use of the BioFire® FilmArray® Meningitis/Encephalitis Panel in immunocompromised and nonimmunocompromised patients.

We implemented the BioFire® FilmArray® Meningitis/Encephalitis Panel (MEP) with guidance for use based on patient age, cerebrospinal fluid (CSF) white blood cell (WBC) count and immune system status. MEPs results over 2 years (1/1/2017 to 12/31/18) were reviewed and clinical significance of positive MEP results in patients with CSF WBC ≤ 10 evaluated. Overall, 12% (51/453) of MEPs were positive with 4/184 (2%) positive in nonimmunocompromised (non-IC) with ≤ 10 CSF WBCs. Among positive results in non-IC patient with ≤10 CSF WBCs, none were judged clinically significant. Four of 6 results in immunocompromised patients with ≤10 CSF WBCs were clinically significant. Redundant testing was common and guideline adherence could have safely decreased MEPs use 41% saving >$56,000. Guideline adherence was poor and MEP use can be safely avoided in non-IC adults with <10 CSF WBC, but clinically significant results did occur in IC patients with low CSF WBC. Clinical decision support could reduce unneeded testing and result in significant cost savings.

Indigocarmine added to the water exchange method enhances adenoma detection - a RCT.

PURPOSE: Chromoendoscopy with dye spray and the water method both increase adenoma detection. HYPOTHESIS: Adding indigocarmine to the water method will enhance further the effectiveness of the latter in adenoma detection. METHODS: Screening colonoscopy was performed with the water method (control) or with 0.008% indigocarmine added (study) by two endoscopists. Randomization was based on computer-generated codes contained in blocks of pre-arranged opaque sealed envelopes. High resolution colonoscopes were used. Upon insertion into the rectum, air was suctioned. With the air pump turned off, water was infused using a blunt needle adaptor connected to the scope channel and a foot pump to facilitate scope insertion until the cecum was reached. Residual stool causing cloudiness was suctioned followed by infusion of clear or colored water (water exchange) to facilitate scope passage with minimal distention of the colonic lumen. Upon seeing the appendix opening under water, water was suctioned and air was insufflated to facilitate inspection on scope withdrawal. STATISTICS: Sample size calculation revealed 168 patients (84/group) needed to be randomized. Study was IRB-approved and registered (NCT01383265). RESULTS: There were no significant differences in mean age, gender distribution, BMI, and family history of colon cancer. Cecal intubation success rate was 100% in both groups. The overall adenoma detection rate was 44% (water only) versus 62% (water with indigocarmine), respectively (p=0.03). One cancer was detected in each group. CONCLUSION: In a RCT, indigocarmine at 0.008% concentration, added to the water method, significantly enhanced further the effectiveness of the latter in detecting adenomas.