Measuring acceptable treatment failure rates for community-acquired pneumonia: potential for reducing duration of treatment and antimicrobial resistance.

OBJECTIVE: This study was designed to establish the rates of treatment failure for community-acquired pneumonia that are acceptable to knowledgeable and experienced physicians, in order to facilitate the interpretation of existing studies and the design of new studies aimed at optimizing the duration of antibiotic therapy. Reducing the duration of antibiotic therapy is one strategy for reducing antibiotic exposure and thereby minimizing the potential for the emergence of antimicrobial resistance. DESIGN: Survey soliciting the acceptable failure rate for treatment given to an adult patient with uncomplicated community-acquired pneumonia treated with standard-of-care therapy in the outpatient setting. Analysis was performed using a modification of established methods of contingent valuation analysis. PARTICIPANTS: Six hundred eighty infectious diseases physicians in North America who were also members of the Emerging Infections Network of the Infectious Diseases Society of America. RESULTS: Three hundred seventy-five (55.1%) of 680 physicians responded to the survey. The median acceptable failure rate for treatment was 13.5%. Five hundred ten respondents (75.0%) found a failure rate of 7.3% acceptable, and 170 respondents (25.0%) found a failure rate of 19.8% acceptable. CONCLUSIONS: This study identified the failure rates for treatment of community-acquired pneumonia that were acceptable to infectious disease physicians. This range of acceptable treatment failure rates may facilitate the design of studies aimed at optimizing the duration of antimicrobial therapy for community-acquired pneumonia.

Use of decolonization to prevent staphylococcal infections in various healthcare settings: results of an Emerging Infections Network survey.

Less than 20% of infectious diseases consultants work in hospitals that routinely employ decolonization therapy for individuals with staphylococcal carriage undergoing elective surgical procedures or for infection control efforts to limit nosocomial transmission of methicillin-resistant Staphylococcus aureus (MRSA). However, infectious diseases consultants frequently encounter patients with recurrent MRSA furunculosis and attempt to decolonize them.

Preventing transmission of multidrug-resistant bacteria in health care settings: a tale of 2 guidelines.

Two guidelines for the control of multidrug-resistant organisms in health care facilities have appeared during the past 3 years--one from the Society for Healthcare Epidemiology of America and one, in draft form, from the Healthcare Infection Control Practices Advisory Committee of the Centers for Disease Control and Prevention. These guidelines reflect universal concern in the infection-control community about today's unprecedented levels of activity of multidrug-resistant organisms and about inadequate or inconsistent application of potentially effective control measures. The 2 guidelines provide detailed reviews of pertinent issues and evidence-based, rated recommendations, which overlap considerably. Recommendations regarding indications for active surveillance cultures and the extent of their use constitute the major divergence. Although implementation of comprehensive control plans for multidrug-resistant organisms advocated by both guidelines will require health care facilities to confront difficult programmatic issues, aggressive and widespread adoption of control measures for multidrug-resistant organisms is urgently needed.

Management of persistent bacteremia caused by methicillin-resistant Staphylococcus aureus: a survey of infectious diseases consultants.

We conducted a survey in 2005 of infectious diseases consultants and asked about persistent bacteremia due to methicillin-resistant Staphylococcus aureus. Many consultants perceived an increase in the frequency of illness, and, when presented with vancomycin minimum inhibitory concentrations approaching the limit of the susceptible range, most consultants indicated that they would switch to newer antimicrobial agents for treatment.

A national survey of the Infectious Diseases Society of America Emerging Infections Network concerning neuraminidase inhibitor prescription practices and pandemic influenza preparations.

This report summarizes the findings of a national survey of infectious diseases consultants regarding their use of neuraminidase inhibitors and the status of their planning for an influenza pandemic. The respondents indicated that government stockpiles should be increased, that many have received requests for antiviral medications, and that additional recommendations regarding the appropriate use of antiviral medications would be helpful.

Experience of infectious diseases consultants with outpatient parenteral antimicrobial therapy: results of an emerging infections network survey.

BACKGROUND: Despite the increasing use of outpatient parenteral antimicrobial therapy (OPAT), little is known about the role of infectious diseases consultants in the process or their perceptions of OPAT. METHODS: In May 2004, the Infectious Diseases Society of America Emerging Infections Network (EIN) surveyed its members to characterize their involvement and experiences with OPAT. RESULTS: Of the 454 respondents (54%) who completed the questionnaire, 426 (94%) indicated that patients in their primary inpatient facility were "frequently" discharged while receiving OPAT, estimating that, on average, 19 patients are discharged from their hospitals while receiving OPAT each month. Although 86% of EIN members stated that they personally order OPAT for some patients, 18% indicated that they have no involvement, and 37% stated they only rarely or occasionally oversee OPAT. EIN members involved in OPAT estimated that approximately 90% of their patients who take OPAT received therapy at home, and the members described variable monitoring and oversight methods. Of the respondents, 68% of providers collectively estimated that they encountered 1951 infectious and serious noninfectious complications of OPAT in the past year. The most frequently used antibiotics included vancomycin, ceftriaxone, and cefazolin, most commonly used for bone and joint infections. CONCLUSIONS: These results testify to the pervasive use of OPAT in today's health care system, the variable role of infectious diseases consultants, and the heterogeneity in oversight and management practices. The widespread use of OPAT and its frequent complications indicate the need for additional studies to establish optimal methods of delivery and management to insure the quality and safety of the process.

Physicians' acceptable treatment failure rates in antibiotic therapy for coagulase-negative staphylococcal catheter-associated bacteremia: implications for reducing treatment duration.

BACKGROUND: Decreasing the duration of antimicrobial therapy is an attractive strategy for delaying the emergence of antimicrobial resistance. Limited data regarding optimal treatment durations for most clinical infections hinder the adoption of this approach and impair optimal physician-patient communication under the shared decision-making model. We aimed to identify acceptable failure rates among infectious disease consultants (IDCs) for treatment of central venous catheter-associated bacteremia. METHODS: A case scenario involving a representative patient who developed central venous catheter-associated bacteremia caused by coagulase-negative staphylococci and who received standard-of-care therapy was distributed to all nonpediatric IDC members of the Infectious Diseases Society of America's Emerging Infections Network in August 2003. Each member was suggested 1 of 10 treatment failure rates and asked whether he or she would accept or reject the given value. Logistic regression was used to evaluate the relationship between specific failure rates offered to respondents and their willingness to accept them using a methodology derived from contingent valuation. RESULTS: Among the 374 respondents (response rate, 54%), the median acceptable failure rate was 6.8%. Thus, one-half of the IDCs would have found a failure rate of 6.8% to be acceptable. Seventy-five percent of IDCs would have found a failure rate of 1.6% to be acceptable, and 25% of IDCs would have found a failure rate as high as 11.9% to be acceptable. CONCLUSIONS: The quantified acceptable failure rates, when used to interpret clinical trial or cohort study results, will help select optimal antimicrobial therapy durations for this specific condition. These findings are a critical step in the development of effective shared decision-making models.

A national survey of severe influenza-associated complications among children and adults, 2003-2004.

This report summarizes findings of a national survey conducted among infectious diseases consultants to assess complications associated with influenza during the 2003-2004 influenza season. The survey identified severe complications, including secondary infection with Staphylococcus aureus and deaths among children and adults, as well as perceived shortages in rapid diagnostic tests and influenza vaccine.

Management of inpatients colonized or infected with antimicrobial-resistant bacteria in hospitals in the United States.

BACKGROUND: Although guidelines for multidrug-resistant organisms generally include recommendations for contact precautions and surveillance cultures, it is not known how frequently U.S. hospitals implement these measures on a routine basis and whether infectious diseases consultants endorse their use. METHODS: The Emerging Infections Network surveyed its members, infectious diseases consultants, to assess their use of and support for contact precautions and surveillance cultures for routine management of multidrug-resistant organisms in their principal inpatient workplace. Specifically, members were asked about use of these strategies for methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, and multidrug-resistant, gram-negative bacilli on general wards, ICUs, and transplant units. RESULTS: Overall, 400 (86%) of 463 respondents supported the routine use of contact precautions to control one or more multidrug-resistant organisms in at least one unit, and 89% worked in hospitals that use them. In contrast, 50% of respondents favored routine use of surveillance cultures to manage at least one multidrug-resistant organism in any unit, and 30% of respondents worked in hospitals that use them routinely in any unit. Members favored routine use of surveillance cultures significantly more in ICUs and transplant units than in general wards for each multidrug-resistant organism (P < .001). CONCLUSIONS: Most of the infectious diseases consultants endorsed the use of contact precautions for routine management of patients colonized or infected with multidrug-resistant organisms and work in hospitals that have implemented them. In contrast, infectious diseases consultants are divided about the role of routine surveillance cultures in multidrug-resistant organism management, and few work in hospitals that use them.

Infectious disease outbreaks in nursing homes: an unappreciated hazard for frail elderly persons.

The common occurrence and dire consequences of infectious disease outbreaks in nursing homes often go unrecognized and unappreciated. Nevertheless, these facilities provide an ideal environment for acquisition and spread of infection: susceptible residents who share sources of air, food, water, and health care in a crowded institutional setting. Moreover, visitors, staff, and residents constantly come and go, bringing in pathogens from both the hospital and the community. Outbreaks of respiratory and gastrointestinal infection predominate in this setting, but outbreaks of skin and soft-tissue infection and infections caused by antimicrobial-resistant bacteria also occur with some frequency.

Hospital preparedness for severe acute respiratory syndrome in the United States: views from a national survey of infectious diseases consultants.

In this survey of infectious diseases consultants, 90% reported that their health care facilities have plans in place to address severe acute respiratory syndrome (SARS). Some plan elements exceed current recommendations, whereas others are less stringent. Resource issues associated with airborne isolation and respirators were reported. Sixty-one percent of the respondents expressed some concern about their facility's preparation and capacity for managing patients with SARS. Recent draft guidance on SARS preparedness from the Centers for Disease Control and Prevention may help address some of these issues.

Role of infectious diseases consultants in management of antimicrobial use in hospitals.

The Infectious Diseases Society of America Emerging Infections Network (EIN) surveyed its members to characterize antimicrobial restriction policies in their hospitals and the involvement of infectious diseases consultants in this process. Of the 502 respondents (73%), 250 (50%) indicated that their hospital pharmacies would not dispense certain antimicrobials without approval of infectious diseases consultants. Moreover, 89% agreed that infectious diseases consultants need to be directly involved in the approval process. At hospitals with control policies, commonly restricted agents included lipid formulations of amphotericin B, carbapenems, fluoroquinolones, piperacillin-tazobactam, and vancomycin. Only 46 EIN members (18%) reported remuneration of infectious diseases consultants for participation in the approval process. Pediatric infectious diseases consultants were more likely to practice in hospitals with restriction policies than were adult infectious diseases consultants (64% vs. 45%; P<.001). Similarly, teaching hospitals were more likely to have antimicrobial-control policies than were nonteaching facilities (60% vs. 17%; P<.001).

Acceptable rates of treatment failure in osteomyelitis involving the diabetic foot: a survey of infectious diseases consultants.

Shortening the duration of antibiotic therapy is an attractive strategy for delaying the emergence of antimicrobial resistance. The paucity of data about optimal treatment durations hinders adoption of this approach. This study used contingent valuation analysis to identify failure rates for treatment of diabetic foot osteomyelitis acceptable to infectious diseases consultants (IDCs). The Infectious Diseases Society of America's Emerging Infections Network (EIN) provided members with the case scenario and 1 of 10 failure rates; members were asked, assuming delivery of standard therapy, if they would accept or reject the given failure rate. The relationship between specific failure rates and the willingness of IDCs to accept them was analyzed. The median acceptable failure rate for EIN members was 18.1%; 75% of IDCs found a failure rate of 7.8% to be acceptable, and 25% found a rate of 28.4% to be acceptable. The methodology used in this study may prove useful in delineating acceptable treatment failure thresholds, an initial step in shortening durations of antimicrobial therapy.

Decision-making on the use of antimicrobial prophylaxis for dental procedures: a survey of infectious disease consultants and review.

There is debate concerning use of antibiotic prophylaxis before invasive dental procedures for patients at risk of acquiring distant site infection (DSI). We determined the opinions and practices of infectious disease consultants (IDCs) regarding antimicrobial prophylaxis to prevent DSIs that result from invasive dental procedures by conducting a survey of the 797 members of the Infectious Diseases Society of America Emerging Infections Network (477 members [60%] responded). Ninety percent of respondents closely follow the American Heart Association guidelines for antibiotic prophylaxis for patients with valvular heart disease who undergo invasive dental procedures. In contrast, few IDCs recommend prophylaxis for patients with lupus erythematosus, poorly controlled diabetes mellitus, dialysis catheters or shunts, cardiac pacemakers, or ventriculoperitoneal shunts. Twenty-five percent to forty percent of respondents recommended prophylaxis for prosthetic vascular grafts, orthopedic implants, or chemotherapy-induced neutropenia. We conclude that IDCs differ considerably in their assessment of the need for prophylaxis for patients who have noncardiac risk factors for DSI. These differences underscore the need for definitive studies to delineate appropriate candidates for antimicrobial prophylaxis in dental practice.

Effectiveness of pharmacy policies designed to limit inappropriate vancomycin use: a population-based assessment.

OBJECTIVE: In Oregon in 1994, a population-based study of 66 nonpsychiatric hospitals indicated that 40% of vancomycin orders were inappropriate according to Centers for Disease Control and Prevention guidelines. We repeated the study to determine whether vancomycin use had been affected by pharmacy policies implemented following the 1994 study. METHODS: We surveyed pharmacists in nonpsychiatric hospitals in Oregon regarding vancomycin use policies in their hospitals. Using pharmacy records, we identified and abstracted the charts of all patients in Oregon hospitals receiving vancomycin during a 3-week period to determine appropriate use of vancomycin. RESULTS: Thirteen (20%) of 64 hospitals had implemented a vancomycin restriction policy since 1994; none ofthe remaining hospitals in the study had a policy. In 1999, hospitals with vancomycin restriction policies had substantially decreased rates of inappropriate vancomycin use compared with hospitals without such policies (1.0 vs 1.8 orders per 1,000 patient-days; P = .01). Compared with 1994 baseline rates of inappropriate use, hospitals that adopted policies experienced a decrease (from 1.5 orders per 1,000 patient-days in 1994 to 1.0 in 1999; P= .13), whereas hospitals without policies experienced a statistically significant increase (from 0.9 orders per 1,000 patient-days in 1994 to 1.8 in 1999; P= .001). Restriction policies were most effective at reducing rates of inappropriate use for treatment of confirmed gram-positive infections and prophylaxis. CONCLUSION: Vancomycin restriction policies were associated with a decrease in inappropriate therapeutic and prophylactic vancomycin use, but had no effect on inappropriate empiric use. Hospitals considering limits regarding inappropriate use should consider implementation of institution-based vancomycin restriction policies as part of an overall strategy.

Clostridium difficile in long-term-care facilities for the elderly.

Antimicrobial agents are among the most frequently prescribed medications in long-term-care facilities (LTCFs). Therefore, it is not surprising that Clostridium difficile colonization and C. difficile-associated diarrhea (CDAD) occur commonly in elderly LTCF residents. C. difficile has been identified as the most common cause of non-epidemic acute diarrheal illness in nursing homes, and outbreaks of CDAD in LTCFs have also been recognized. This position paper reviews the epidemiology and clinical features of CDAD in elderly residents of LTCFs and, using available evidence, provides recommendations for the management of C. difficile in this setting.

Tuberculosis prevention and control in long-term-care facilities for older adults.

In the United States, older adults comprise 22% of cases of tuberculous disease but only 12% of the population. Most cases of tuberculosis (TB) occur in community dwellers, but attack rates are highest among frail residents of long-term-care facilities. The detection and treatment of latent TB infection and TB disease can pose special challenges in older adults. Rapid recognition of possible disease, diagnosis, and implementation of airborne precautions are essential to prevent spread. It is the intent of this evidence-based guideline to assist healthcare providers in the prevention and control of TB, specifically in skilled nursing facilities for the elderly.

Bacterial infections associated with blood transfusion: experience and perspective of infectious diseases consultants.

BACKGROUND: On March 1, 2004, the AABB adopted a new standard that requires member blood banks and transfusion services to implement measures to limit and detect bacterial contamination in all platelet (PLT) components. The AABB has since developed several guidelines to assist blood transfusion services and blood banks in this area, some of which are relevant to clinical practice. Knowledge and experience among clinicians (including infectious disease consultants, who can play an important role in managing patients with sepsis) concerning risk of bacterial infections associated with transfusion, however, are unknown. STUDY DESIGN AND METHODS: Experience concerning management and prevention of transfusion-associated bacterial infection, including knowledge of the AABB standard requiring bacterial screening of PLTs, was assessed through an Infectious Diseases Society of America Emerging Infections Network (IDSA/EIN) survey. RESULTS: Overall, 405 (47%) EIN members responded to the survey; of those responding, 12 percent of respondents had encountered transfusion reactions potentially due to bacterial contamination in the prior 10 years, 36 percent were aware of the transmission risk of bacteria through blood transfusion, and 20 percent were aware of the new AABB standard for bacterial screening of PLTs. CONCLUSIONS: Understanding by EIN infectious disease consultants of the significance of transfusion-associated bacterial infection and associated AABB standards and guidelines may indicate lack of other clinicians' awareness on these issues. Improving awareness of the risk of bacterial contamination of PLTs appears warranted to improve clinical management of infected blood donors or recipients, particularly when follow-up for transfusion of a culture-positive PLT unit is needed.

Vertebral osteomyelitis.

Preview Bacterial infection of the spine is an uncommon disorder that causes the common symptom of back or neck pain. Prompt diagnosis and initiation of antimicrobial therapy are essential if patients are to avoid serious complications. What factors predispose some persons to vertebral osteomyelitis? Which imaging tools are most helpful in making the diagnosis and guiding biopsy or aspiration? The author answers these questions and discusses management options.

Toxic shock syndrome.

Preview Toxic shock syndrome is no longer a disease that affects only young, menstruating women. Staphylococcal toxic shock syndrome has been diagnosed with increasing frequency in children, men, and older women, and a streptococcal syndrome affecting both sexes and all age-groups has been identified. The variant presentations of these infections can make diagnosis difficult. Dr Strausbaugh describes the features of both the staphylococcal and the streptococcal forms of toxic shock syndrome and offers tips for rapid recognition.