Factors and outcomes associated with the decision to treat primary pulmonary coccidioidomycosis.

BACKGROUND: Studies that assess the value of initiating oral antifungal therapy to treat primary pulmonary coccidioidomycosis have not been published previously. METHODS: Prospectively collected observational data were analyzed from patients with primary pulmonary coccidioidomycosis who attended a single clinic devoted to the management of coccidioidomycosis that is located in a region of coccidioidal endemicity. RESULTS: Fifty-four of 105 patients with primary pulmonary coccidioidomycosis were prescribed antifungal therapy, whereas 51 were not. No statistically significant differences were found between the 2 groups with regard to age, ethnicity, sex, or the presence or type of underlying diseases (for all, P > .100). Treated patients had a higher total clinical score (P = .001), had a higher symptom score (P = .049), and were more likely to have a culture of sputum that was positive for Coccidioides species (P = .048), compared with patients who were not prescribed therapy. There was prospective in-clinic follow-up for 43 patients, for a median duration of 286 days (range, 35-1124 days). The health of all 16 patients who were not treated improved after a median of 217 days, and no patients developed complications during follow-up. However, 2 of 20 patients who were treated but whose therapy was subsequently stopped developed disseminated disease. The rate of clinical improvement was similar in treated and untreated patients (P = .899). A retrospective follow-up of 58 of the remaining 62 patients identified 6 additional patients with complications, all from the group that was initially treated but whose therapy was subsequently discontinued. CONCLUSIONS: Approximately one-half of patients with primary pulmonary coccidioidomycosis were prescribed antifungal therapy on the basis of clinical severity. Complications were seen only among patients in the group that was prescribed therapy but whose treatment was discontinued.

A Multidisciplinary Approach to Incorporate Bedside Nurses into Antimicrobial Stewardship and Infection Prevention.

BACKGROUND: Antimicrobial stewardship programs exist to promote appropriate antimicrobial use. The Joint Commission has reported that although many US hospitals have implemented basic components of antimicrobial stewardship programs, there now exists a need for innovative, multidisciplinary approaches, including involving frontline clinicians such as bedside nurses. METHODS: A retrospective evaluation of bedside nurse-driven antimicrobial stewardship and infection prevention rounds was conducted on a 31-bed telemetry unit of a community regional medical center. Rounds were managed by a nurse coordinator and attended by an infectious diseases pharmacist, an infection preventionist, and a nurse practitioner. Primary outcome measures were antimicrobial and acid suppressant medication and invasive catheter use. RESULTS: In the 12-month intervention period the nurse-driven rounds team reviewed of a total of 472 antimicrobial medication, 480 acid suppressant medication, 321 urinary catheter, and 61 central venous catheter therapies over 867 total patient encounters. Compared with the 12-month preintervention period, significant reductions in unit antimicrobial use (791.2 vs. 697.1 days of therapy per 1,000 patient-days; p = 0.03), acid suppressant medication use (708.1 vs. 372.4 days of therapy per 1,000 patient-days; p = 0.0001), and urinary catheter use (0.3 vs. 0.2 catheter-days per patient-day; p = 0.002) were observed. CONCLUSION: This study demonstrates successful engagement of bedside nurses in antimicrobial stewardship and infection prevention activities and a measurable impact on meaningful outcomes. More studies of strategies to integrate bedside nurses in antimicrobial stewardship are needed.

Fatigue in coccidioidomycosis. Quantification and correlation with clinical, immunological, and nutritional factors.

While described in the past, the frequency and degree of fatigue associated with symptomatic coccidioidomycosis has never been quantified. Using the Fatigue Severity Scale (FSS), severe fatigue (FSS score = 41) was found in 65% of cases of active coccidioidomycosis compared to 42% in cohort of control subjects with chronic medical diseases (P=0.024). Fatigue in patients with symptomatic coccidioidomycosis declined significantly over four months (P=0.023). Severe fatigue in patients with symptomatic coccidioidomycosis was significantly associated with low body mass index (BMI; P=0.024) but was not significantly associated with either serum leptin (r2=0.078, P=0.261) or serum TNF-alpha (r2=0.028, P=0.504) concentrations. Severe fatigue is a common condition among patients with active coccidioidomycosis and is associated with a declining BMI.