Impact of a Multifaceted Intervention on Antibiotic Prescribing for Cystitis and Asymptomatic Bacteriuria in 23 Community Hospital Emergency Departments.

Background: Urinary tract infections (UTIs) are over-diagnosed and over-treated in the emergency department (ED) leading to unnecessary antibiotic exposure and avoidable side effects. However, data describing effective large-scale antimicrobial stewardship program (ASP) interventions to improve UTI and asymptomatic bacteriuria (ASB) management in the ED are lacking. Methods: We implemented a multifaceted intervention across 23 community hospital EDs in Utah and Idaho consisting of in-person education for ED prescribers, updated electronic order sets, and implementation/dissemination of UTI guidelines for our healthcare system. We compared ED UTI antibiotic prescribing in 2021 (post-intervention) to baseline data from 2017 (pre-intervention). The primary outcomes were the percent of cystitis patients prescribed fluoroquinolones or prolonged antibiotic durations (>7 days). Secondary outcomes included the percent of patients treated for UTI who met ASB criteria, and 14-day UTI-related readmissions. Results: There was a significant decrease in prolonged treatment duration for cystitis (29% vs 12%, P < .01) and treatment of cystitis with a fluoroquinolone (32% vs 7%, P < .01). The percent of patients treated for UTI who met ASB criteria did not change following the intervention (28% pre-intervention versus 29% post-intervention, P = .97). A subgroup analysis indicated that ASB prescriptions were highly variable by facility (range 11%-53%) and provider (range 0%-71%) and were driven by a few high prescribers. Conclusions: The intervention was associated with improved antibiotic selection and duration for cystitis, but future interventions to improve urine testing and provide individualized prescriber feedback are likely needed to improve ASB prescribing practice.

Genomic relationships among sixteen species of Avena based on (ACT)6 trinucleotide repeat FISH.

Knowledge of the locations of repeat elements could be very important in the assembly of genome sequences and their assignment to physical chromosomes. Genomic and species relationships among 16 species were investigated using fluorescence in situ hybridization (FISH) with the Am1 and (ACT)6 probes. The Am1 oligonucleotide probe was particularly enriched in the C genomes, whereas the (ACT)6 trinucleotide repeat probe showed a diverse distribution of hybridization patterns in the A, AB, C, AC, and ACD genomes but might not be present in the B and D genomes. The hybridization pattern of Avena sativa was very similar to that of A. insularis, indicating that this species most likely originated from A. insularis as a tetraploid ancestor. Although the two FISH probes failed to identify relationships of more species, this proof-of-concept approach opens the way to the use of FISH probes in assigning other signature elements from genomic sequence to physical chromosomes.

Outcomes of patients with bacteriuria/pyuria of clinically undetermined significance (BPCUS) treated with antibiotics in 23 community hospital emergency departments.

The optimal management of bacteriuria/pyuria of clinically undetermined significance (BPCUS) is unknown. Among 220 emergency department patients prescribed antibiotics for BPCUS, we found frequent readmissions, which were mitigated by outpatient follow-up visits. Observation and follow-up for an unknown diagnosis should be emphasized over antibiotics due to high likelihood of readmissions.

A Novel Program to Provide Drug Recovery Assistance and Outpatient Parenteral Antibiotic Therapy in People Who Inject Drugs.

BACKGROUND: Safe hospital discharge on parenteral antibiotic therapy is challenging for people who inject drugs (PWID) admitted with serious bacterial infections (SBI). We describe a Comprehensive Care of Drug Addiction and Infection (CCDAI) program involving a partnership between Intermountain Healthcare hospitals and a detoxification facility (DF) to provide simultaneous drug recovery assistance and parenteral antibiotic therapy (DRA-OPAT). METHODS: The CCDAI program was evaluated using a pre-/poststudy design. We compared outcomes in PWID hospitalized with SBI during a 1-year postimplementation period (2018) with similar patients from a historical control period (2017), identified by propensity modeling and manual review. RESULTS: Eighty-seven patients were candidates for the CCDAI program in the implementation period. Thirty-five participants (40.2%) enrolled in DRA-OPAT and discharged to the DF; 16 (45.7%) completed the full outpatient parenteral antibiotic therapy (OPAT) duration. Fifty-one patients with similar characteristics were identified as a preimplementation control group. Median length of stay (LOS) was reduced from 22.9 days (interquartile interval [IQI], 9.8-42.7) to 10.6 days (IQI, 6-17.4) after program implementation (P < .0001). Total median cost decreased from $39 220.90 (IQI, $23 300.71-$82 506.66) preimplementation to $27 592.39 (IQI, $18 509.45-$48 369.11) postimplementation (P < .0001). Ninety-day readmission rates were similar (23.5% vs 24.1%; P = .8). At 1-year follow-up, all-cause mortality was 7.1% in the preimplementation group versus 1.2% postimplementation (P = .06). CONCLUSIONS: Partnerships between hospitals and community resources hold promise for providing resource-efficient OPAT and drug recovery assistance. We observed significant reductions in LOS and cost without increases in readmission rates; 1-year mortality may have been improved. Further study is needed to optimize benefits of the program.

Clostridium botulinum - like organism bacteremia in a user of black tar heroin.

Wound botulism due to introduction of the anaerobic bacteria, Clostridium botulinum, into otherwise sterile, relatively anaerobic tissue is a known complication of black tar heroin use. The treatment of wound botulism requires prompt initiation of antitoxin as well as antimicrobial therapy. We report the case of a patient with polymicrobial bacteremia that included a Clostridium botulinum-like organism who underwent successful treatment of their anaerobic infection with antibiotics and surgical debridement.

Interventions to optimize antimicrobial stewardship.

Developing and improving an antimicrobial stewardship program successfully requires evaluation of numerous factors. As technology progresses and our understanding of antimicrobial resistance grows, careful consideration should be taken to ensure that a program meets the needs of the institution and is achievable given the available resources. In this review, we explore fundamental initiatives and strategies for both new and established antimicrobial stewardship programs, including the specific areas to target and key elements required for sustainable implementation.

Genetic and physical mapping of Lrk10-like receptor kinase sequences in hexaploid oat (Avena sativa L.).

Oat receptor-like kinase gene sequences, homologous to the Lrk10 gene from wheat (Triticum aestivum L.), were mapped in oat (Avena sativa L.). PCR primers designed from the wheat Lrk10 were used to produce ALrk10 from oat. Two DNA sequences, ALrk1A1 and ALrk4A5, were produced from primers designed from coding and noncoding regions of ALrk10. Their use as RFLP probes indicated that the kinase genes mapped to four loci on different hexaploid oat 'Kanota' x 'Ogle' linkage groups (4_12, 5, 6, and 13) and to a fifth locus unlinked to other markers. Three of these linkage groups contain a region homologous to the short arm of chromosome I of wheat and the fourth contains a region homologous to chromosome 3 of wheat. Analysis with several nullisomics of oat indicated that two of the map locations are on satellite chromosomes. RFLP mapping in a 'Dumont' x 'OT328' population indicated that one map location is closely linked to Pg9, a resistance gene to oat stem rust (Puccinia graminis subsp. avenae). Comparative mapping indicates this to be the region of a presumed cluster of crown rust (Puccinia coronata subsp. avenae) and stem rust resistance genes (Pg3, Pg9, Pc44, Pc46, Pc50, Pc68, Pc95, and PcX). The map position of several RGAs located on KO6 and KO3_38 with respect to Lrk10 and storage protein genes are also reported.