Beta-lactam comprehensive allergy management program in a community medical center.

Objective: The Beta-lactam Comprehensive Allergy Management Program (CAMP) was implemented to facilitate complete beta-lactam allergy history documentation in the electronic medical record (EMR) and increase beta-lactam utilization. The study objective was to assess the rate of complete allergy histories and days of antimicrobial therapy (DOT) before versus after CAMP implementation. Design: Quasi-experimental study with interrupted time-series analysis. Setting: Non-teaching, urban, and community medical center within a multi-hospital health system. Patients: Adult inpatients with a beta-lactam allergy receiving antimicrobial therapy. Methods: The multidisciplinary CAMP team screened, interviewed, and collected allergy history details of adult inpatients with a beta-lactam allergy receiving antimicrobial therapy starting January 4, 2021. Patients were stratified as high, moderate, or low risk of IgE-mediated allergy and referred to an allergist for skin testing or drug challenge. The EMR was updated with interview details and drug challenge or skin test results. The primary endpoint was rate of complete allergy history documentation before (12/1/18-4/1/19) compared to after (1/4/21-5/1/21) program implementation. The secondary endpoint was days of inpatient beta-lactam therapy. Implementation logistics, de-labeling rate, and antimicrobial therapy changes were evaluated. Results: The program evaluated 392 individuals, with 184 and 208 patients comprising the pre- and post-intervention groups, respectively. The post-intervention period was associated with an increase of 19.8% in complete allergy histories (0.359 PPc; R 2 0.26; p = 0.002) and 9.34 beta-lactam DOT per 1,000-days-present (1.106 PPc; R 2 0.194; p = 0.009). Conclusion: Implementation of a comprehensive beta-lactam allergy management program was associated with higher rates of complete beta-lactam allergy history and beta-lactam use.

Impact of Tocilizumab on Clinical Outcomes in COVID-19-Associated Cytokine Release Syndrome: A Single-Center Experience.

BACKGROUND: Tocilizumab is an interleukin-6 receptor antagonist hypothesized to blunt the uncontrolled immune response, cytokine release syndrome, in severe COVID-19 and prevent attributable morbidity and mortality. Objective: The objective of this study was to assess the impact of tocilizumab on clinical outcomes in COVID-19-associated cytokine release syndrome. METHODS: Single-center, retrospective cohort study assessing sixty-nine adult patients receiving tocilizumab for suspected COVID-19 cytokine release syndrome. The primary outcome was change in WHO clinical status scale on day seven post-dose analyzed using the Wilcoxon signed rank test. Secondary outcomes assessed impact of timing of administration on clinical outcome. Safety analyses included development of neutropenia, thrombocytopenia, transaminitis, and sepsis within 7 days post-dose. Statistical analyses were conducted using Microsoft Excel. RESULTS: No aggregate clinical change was found between day 0 and day 7. Eleven patients improved, twenty-seven worsened, and thirty-one showed no change. Clinical outcomes were weakly correlated with time from symptom onset (rs = 0.21; p = 0.08) or hospital admission (rs = -0.08; p = 0.49) to dose. In-hospital mortality was 63%. Sepsis was diagnosed in 21 patients, five of which were post-dose. Transaminitis, neutropenia, and thrombocytopenia occurred in seven, one, and six patients, respectively. CONCLUSION: Tocilizumab did not appear to influence clinical outcomes in our study population, irrespective of timing of administration. Adverse events were not considered drug-related.

Antibiotic Misuse in Wound Care: Can Bacterial Localization through Fluorescence Imaging Help?

(1) Background: Systemic antibiotic use in chronic wounds is alarmingly high worldwide. Between 53% to 71% of patients are prescribed at least one course per chronic wound. Systemic antibiotic use should follow antibiotic stewardship guidelines and ought to be reserved for situations where their use is deemed supported by clinical indications. Unfortunately, in the field of wound care, indiscriminate and often inadequate use of systemic antibiotics is leading to both patient complications and worsening antibiotic resistance rates. Implementing novel tools that help clinicians prevent misuse or objectively determine the true need for systemic antibiotics is essential to reduce prescribing rates. (2) Methods: We present a compendium of available systemic antibiotic prescription rates in chronic wounds. The impact of various strategies used to improve these rates, as well as preliminary data on the impact of implementing fluorescence imaging technology to finesse wound status diagnosis, are presented. (3) Results: Interventions including feedback from wound care surveillance and treatment data registries as well as better diagnostic strategies can ameliorate antibiotic misuse. (4) Conclusions: Interventions that mitigate unnecessary antibiotic use are needed. Effective strategies include those that raise awareness of antibiotic overprescribing and those that enhance diagnosis of infection, such as fluorescence imaging.

A retrospective study of cryopreserved umbilical cord as an adjunctive therapy to promote the healing of chronic, complex foot ulcers with underlying osteomyelitis.

Complex lower extremity ulcers with exposed bone, tendon, muscle, and/or joint capsule as well as multiple comorbidities including diabetes, ischemia, and underlying osteomyelitis are difficult to heal and associated with high morbidity and mortality and high rates of amputation. A retrospective review was performed to assess healing of 31 patients presenting with 33 complex foot ulcers with a confirmed histopathological diagnosis of osteomyelitis treated by the same surgeon at a single wound care center by the following treatment regimen: sharp debridement, resection of infected bone when necessary, open cortex, antibiotics, and application of cryopreserved umbilical cord (cUC). The average ulcer size was 15.6 ± 17.7 cm2 (0.4-73.95 cm2 ). Overall, 26 out of the 33 wounds achieved complete closure (78.8%). Five patients were lost to follow-up and one patient expired during the course of treatment, not believed to be treatment related. Of the remaining 27 wounds in patients not lost to follow-up, 26 achieved complete healing with an average time to healing of 16 weeks and an average of 1.24 applications of cUC. The results suggest that cUC used as an adjunctive tissue therapy in conjunction with surgical debridement, resection of infected bone, open cortex, and antibiotic treatment may be an effective overall treatment strategy to promote wound healing of complex foot ulcers associated with osteomyelitis. The preliminary results are encouraging and warrant further randomized control studies to determine whether cUC might help address such an unmet medical need.

A prospective randomised controlled clinical trial comparing hydrosurgery debridement with conventional surgical debridement in lower extremity ulcers.

Debridement of devitalised tissue is an essential component of the effective treatment of chronic wounds. The Versajet Hydrosurgery System is a new technology that simultaneously cuts and aspirates soft tissue. In this study we compared Versajet with conventional surgical techniques in the debridement of lower extremity ulcers to assess impact on time and resources for debridement. Forty-one patients with a mean age of 68 years (range 33 to 95 years) underwent surgical debridement of a lower extremity ulcer. Operating room (OR) sessions were randomised to Versajet (n= 22) or conventional debridement (n= 19) with scalpel plus pulsed lavage. Procedure time and utilisation of consumables were recorded. Wound areas were monitored for 12 weeks. There was significant evidence (P < 0.008) of a shorter debridement time (10.8 min) using Versajet over conventional debridement (17.7 min); a mean saving of 6.9 minutes (39%). In addition, a significant reduction in use of pulsed lavage and saline (P < 0.001) was observed with Versajet. Overall, clinical efficacy of the shorter debridement procedure was similar: median time to wound closure 71 days (Versajet) vs. 74 days (conventional) (P= 0.733). We found Versajet to be quicker than conventional debridement in the debridement of lower extremity ulcers without compromising wound healing. Potential cost savings were identified from the use of VERSAJET through the shorter debridement time allowing more patients to be treated in the same operating schedule.