The Practice of Antimicrobial Stewardship in Thoracic Surgery and its Effectiveness.

This study examines the effects of the bundle of antimicrobial stewardship measures for prophylactic antibiotics among thoracic surgery patients. A local protocol, based on current guidelines starting from December 2014, was developed by the Infection Control and Thoracic Surgery Teams. The effects of this protocol were assessed by monitoring a total of 1380 patients before and after its implementation from January 1, 2011, to December 31, 2022.

An international multicenter study comparing COVID-19 omicron outcomes in patients with hematological malignancies treated with obinutuzumab versus rituximab.

OBJECTIVES: Hematological malignancy (HM) patients treated with anti-CD20 monoclonal antibodies are at higher risk for severe COVID-19. A previous single-center study showed worse outcomes in patients treated with obinutuzumab compared to rituximab. We examined this hypothesis in a large international multicenter cohort. METHODS: We included HM patients from 15 centers, from five countries treated with anti-CD20, comparing those treated with obinutuzumab (O-G) to rituximab (R-G) between December 2021 and June 2022, when Omicron lineage was dominant. RESULTS: We collected data on 1048 patients. Within the R-G (n = 762, 73%), 191 (25%) contracted COVID-19 compared to 103 (36%) in the O-G. COVID-19 patients in the O-G were younger (61 ± 11.7 vs. 64 ± 14.5, p = 0.039), had more indolent HM diagnosis (aggressive lymphoma: 3.9% vs. 67.0%, p < 0.001), and most were on maintenance therapy at COVID-19 diagnosis (63.0% vs. 16.8%, p < 0.001). Severe-critical COVID-19 occurred in 31.1% of patients in the O-G and 22.5% in the R-G. In multivariable analysis, O-G had a 2.08-fold increased risk for severe-critical COVID-19 compared to R-G (95% CI 1.13-3.84), adjusted for Charlson comorbidity index, sex, and tixagevimab/cilgavimab (T-C) prophylaxis. Further analysis comparing O-G to R-G demonstrated increased hospitalizations (51.5% vs. 35.6% p = 0.008), ICU admissions (12.6% vs. 5.8%, p = 0.042), but the nonsignificant difference in COVID-19-related mortality (n = 10, 9.7% vs. n = 12, 6.3%, p = 0.293). CONCLUSIONS: Despite younger age and a more indolent HM diagnosis, patients receiving obinutuzumab had more severe COVID-19 outcomes than those receiving rituximab. Our findings underscore the need to evaluate the risk-benefit balance when considering obinutuzumab therapy for HM patients during respiratory viral outbreaks.

COVID-19 associated bacterial infections in intensive care unit: a case control study.

We described the secondary bacterial infections (SBI) among COVID-19 patients in comparison with non-COVID-19 patients. We performed a retrospective case-control study between January 01, 2020 and April 01, 2022. Including the adult patients, who stayed ≥ 72 h in intensive care unit (ICU). In total 405 patients were included, 135 had (33.3%) COVID-19, with similar age and gender. The length of stay in ICU was not different (11.4 vs 8.2, p = 0.109), however mean intubation days were higher among COVID-19 cases (6.5 vs 3.8, p = 0.005), SBI were more common among COVID-19 cases (34% vs 10.7%, p < 0.001). Among the patients with pneumonia, the rate of gram-positive bacteria was higher in COVID-19 group than the control group (39% vs 5%, p = 0.006). The predictors for SBI were having COVID-19 (OR: 2.3, Cl 1.25-4.32, p = 0.008), days of intubation (OR: 1.05, Cl 1.01-1.10, p = 0.004), and being male (OR: 2, Cl 1.12-3.58, p = 0.018). The predictors of mortality were COVID-19 (OR: 2.38, Cl 1.28-4.42, p = 0.006), days of intubation (OR: 1.06, Cl 1.03-1.09, p < 0.001), active hematologic malignancy (OR: 3.1, Cl: 1.33-7.28, p = 0.09), active solid tumors (OR: 2.44, Cl 1.21-4.91, p = 0.012), and coronary artery diseases (OR: 1.8, Cl 1.01-3.52, p = 0.045). The most common SBI in COVID-19 patients were methicillin-sensitive Staphylococcus aureus. No carbapenem-resistant Enterobacterales related infections were detected in COVID-19 patients.

The Effect of Vaccination with Pfizer-BioNTech or CoronaVac on Disease Prognosis Among Hospitalized COVID-19 Patients.

Objective: The Turkish Ministry of Health offered two types of vaccines by January 13, 2021, which are CoronaVac (Sinovac Biotech, China) and Pfizer-BioNTech. We aimed to describe the impact of the CoronaVac and Pfizer-BioNTech vaccines on clinical outcomes among hospitalized patients during a six-month period. Methods: We included patients older than 18 years old and hospitalized because of COVID-19 when the vaccines were available. We conducted the study at Koç University Hospital and American Hospital between June 2021, six months after the vaccination started, and December 2021. Results: In total, 444 RT-PCR confirmed hospitalized patients were included. The mean age of the patients was 59 (standard deviation [SD]=18), and 42.8% were female. The most common comorbidity was hypertension (39%), followed by diabetes mellitus (27%), cardiovascular diseases (18.4%), chronic lung diseases (14.6%), cancer (9.2%), and chronic renal diseases (8%). In multivariate analysis, no vaccination (OR=4.7, CI=2.25-10.06; p<0.001), age >65 (OR=5.2, CI=2.25-11.98; p<0.001), cancer (OR=7.6, CI=3.04-19.31; p<0.001), and chronic kidney disease (OR=3.1, CI=1.14-8.74; p=0.026) significantly increased mortality in COVID-19 patients. Eighteen percent of patients were in the intensive care unit (ICU). One hundred eighty-one patients (40.8%) were non-vaccinated before their admission, and their mortality (17.6%) was higher compared to the patients who were vaccinated with at least one type of vaccine (p=0.002). None of the patients who received two doses of Pfizer-BioNTech vaccines died. Conclusion: Among the inpatients with COVID-19, the predictors for mortality were being unvaccinated, older age, cancer, chronic kidney disease, and cardiovascular diseases. Among the vaccinated inpatients, having two doses of the Pfizer-BioNTech vaccine was the only effective protective measure against mortality, and two doses of the CoronaVac vaccine had no significant effect in preventing fatality.

Challenges in Diagnosis and Treatment of Fasciola hepatica Infection.

A 57-year-old female patient presented with fever, nausea, vomiting, loss of appetite, and weight loss within the last two months. Ceftriaxone and metronidazole therapy was started upon discovery of a liver abscess but provided no benefit. Following the of abscess biopsy, the patient developed fever, itching, anemia, acute renal failure, hyperbilirubinemia, and eosinophilia that required intensive care unit (ICU) admission. The Fasciola hepatica antibodies were detected by enzyme-linked immunosorbent assay (ELISA). Triclabendazole was started, after which the symptoms and magnetic resonance imaging (MRI) findings regressed. Even without eosinophilia, F. hepatica should be considered in cases with a liver abscess that does not respond to antibiotics.

Appropriate use of tocilizumab in COVID-19 infection.

OBJECTIVE: This study aimed to describe the effectiveness and optimum use of tocilizumab (TCZ) treatment by the support of clinical, laboratory and radiologic observations. METHODS: All patients were followed up in the hospital with daily interleukin-6 (IL-6), C-reactive protein (CRP), ferritin, d-dimer, full blood count, and procalcitonin. Thoracic computed tomography (CT) was performed on admission, when oxygen support was necessary, and seven days after TCZ started. Disease course of the patients was grouped as severe or critical, according to their clinical, laboratory and radiologic evaluations. RESULTS: Forty-three patients were included: 70% were male; the median age was 64 years (minimum-maximum: 27-94); and six (14%) patients died. The median duration of oxygen support before the onset of TCZ was shorter among the severe patient group than the critical patient group (1 vs. 4 days, p < 0.001). Three cases of 21 (14%) who received TCZ in the ward were transferred to ICU, and none of them died. The levels of IL-6, CRP, ferritin, d-dimer, and procalcitonin were significantly lower in the severe cases group than the critical cases group (p = 0.025, p = 0.002, p = 0.008, p = 0.002, and p = 0.001, respectively). Radiological improvement was observed in severe cases on the seventh day of TCZ. Secondary bacterial infection was detected in 41% of critical cases, but none of the severe ones. CONCLUSION: Earlier use of TCZ in COVID-19 infection was beneficial for survival, length of hospitalization and duration of oxygen support. The recommendation for administration of TCZ was based on an increase in requirement of oxygen support, progression in thoracic CT, and elevation of inflammation markers, including IL-6, CRP, ferritin, and d-dimer, and decrease in % lymphocytes.

Bortezomib induced pulmonary toxicity: a case report and review of the literature.

Bortezomib is widely used in the treatment of Multiple Myeloma. While the most common side effects are neurological and gastrointestinal related complications, severe pulmonary problems are rarely described. The present case is a 72-year old male with multiple myeloma, who received Lenalidomide, Bortezomib, and Dexamethasone (RVD) combination regimen. He underwent 30 Gy palliative radiotherapy to the thoracic 5-9 and lumbar L1-3 vertebra due to pain and fracture risk. During the third cycle, he was admitted to hospital with dyspnea and dizziness. The thoracic CT revealed bilateral pleural effusions, a diffuse reticular pattern on the parenchyma, and ground-glass opacities that were compatible with drug-induced lung injury. The microbiological and molecular analysis excluded infectious disease, and lung biopsy confirmed the diagnosis of Bortezomib Lung Injury. The time from the first dose of Bortezomib to the lung injury was 57 days, and it was five days from the last dose of Bortezomib. His symptoms were refractory to IV steroids and supportive care. Our patient was lost despite steroids and intensive care support. Even Bortezomib induced lung injury is a rare adverse effect, based on high mortality rate, we would like to emphasize the clinical importance of this clinical scenario in light of the published literature and our presented case.

The rapid diagnosis of viral respiratory tract infections and its impact on antimicrobial stewardship programs.

We aimed to describe the potential benefit of new rapid molecular respiratory tests (MRT) in decreasing inappropriate antibiotic use among the inpatients presenting with influenza-like illness (ILI). We included patients from inpatient and outpatient departments who had ILI and performed MRT between 1 January 2015 and 31 December 2016 in a 265-bed private hospital in Istanbul. At the end of 2015, we implemented antimicrobial stewardship including systematic use of MRT. Then, we compared our observations between the year 2015 and the year 2016. We designed the study according to the STrengthening the Reporting of OBservational studies in Epidemiology (STROBE) tool. A U.S. Food and Drug Administration (FDA)-cleared multiplexed polymerase chain reaction (PCR) system (BioFire FilmArray, Idaho Technology, Salt Lake City, UT) which detects 17 viruses and three bacteria was used for diagnosis. In total, 1317 patients were included; 630 (48%) were inpatients and 569 (43%) were older than 16 years of age. At least one virus was detected in 747 (57%) patients. Rhinovirus/enterovirus, influenza virus, and adenovirus were the most commonly detected. Among hospitalized patients, in children, a significant decrease in antibiotic use (44.5% in 2015 and 28.8% in 2016, p = 0.009) was observed, but in adults, the decrease was not statistically significant (72% in 2015 and 63% in 2016, p = 0.36). The duration of antibiotic use after the detection of virus was significantly decreased in both children and adults (p < 0.001 and p = 0.007, respectively). By using MRT, inappropriate antibiotic use and, also, duration of inappropriate antibiotic use after the detection of virus was significantly decreased. It is time to increase the awareness about the viral etiology in respiratory tract infections (RTIs) and implement MRT in clinical practice.

Implementation of an antimicrobial stewardship program for patients with febrile neutropenia.

BACKGROUND: We aimed to describe the effectiveness of our standardized protocol for febrile neutropenia (FN), which was targeted to minimize unintended outcomes and reduce antimicrobial consumption. METHODS: The study was performed in a private hospital with 300 beds. We included all adult hematologic and oncologic cancer inpatients admitted between January 1, 2015-December 31, 2015, and January 1, 2016-May 31, 2017. The outcomes of the study were fatality, infections, and adherence to the antimicrobial stewardship program (ASP). RESULTS: We included 152 FN attacks of 95 adult inpatients from hematology and oncology wards; of these, 43% were women, and the median age was 57 years. The case fatality rate was 30% in the pre-ASP period and decreased to 11% in the post-ASP period (P = .024). The appropriate adding or changing (P = .006) and appropriate continuation or de-escalation or discontinuation of antimicrobials improved (P < .001). In the post-ASP period, Staphylococcus spp infections (from 22% to 8%, P = .02) and gram-negative infections decreased (from 43% to 20%, P = .003). In the multivariate analysis, appropriate continuation or de-escalation or discontinuation was increased in the post-ASP period (odds ratio [OR], 4.3; 95% confidence interval [CI], 1.82-10.41; P = .001), and gram-positive infections were decreased (OR, 0.32; 95% CI, 0.11-0.95, P = .041). Vancomycin and fluoroquinolone use decreased significantly. CONCLUSIONS: After implementation of the ASP, the case fatality rate among the patients with FN decreased. Appropriate antimicrobial use increased and overall antimicrobial consumption was reduced. Bacterial infections and Candida infections decreased.

Pityriasis rosea associated with pegylated interferon alfa and ribavirin treatment in a patient with chronic hepatitis C.

BACKGROUND: Pityriasis rosea is an acute inflamatory skin disease that the etiology is unknown but some viral agents like human herpes virus-6 and 7 and drugs are suspected. CASE REPORT: A-58-year-old man with chronic hepatitis C was being followed up in our hospital. Pegylated interferon (PEG-IFN) alfa-2b (100 µg per week) and ribavirin (1000 mg/day) was started. In the third month of this treatment, the patient was diagnosed with pityriasis rosea (PR), which was confirmed by skin biopsy. PEG-IFN alfa-2b treatment for chronic hepatitis C was maintained and no therapy was given for PR. The lesions spontaneously improved within 5 weeks. CONCLUSION: Interferon and ribavirin have several cutaneous side effects. Our case is the first case of PR, emerged in a patient with chronic hepatitis C while receiving PEG-IFN alfa 2b and ribavirin.