Increasing Experience with Primary Oral Medical Therapy for Mycobacterium ulcerans Disease in an Australian Cohort.

Buruli ulcer (BU) is a necrotizing infection of subcutaneous tissue that is caused by Mycobacterium ulcerans and is responsible for disfiguring skin lesions. The disease is endemic to specific geographic regions in the state of Victoria in southeastern Australia. Growing evidence of the effectiveness of antibiotic therapy for M. ulcerans disease has evolved our practice to the use of primarily oral medical therapy. An observational cohort study was performed on all confirmed M. ulcerans cases treated with primary rifampin-based medical therapy at Barwon Health between October 2010 and December 2014 and receiving 12 months of follow-up. One hundred thirty-two patients were managed with primary medical therapy. The median age of patients was 49 years, and nearly 10% had diabetes mellitus. Lesions were ulcerative in 83.3% of patients and at WHO stage 1 in 78.8% of patients. The median duration of therapy was 56 days, with 22 patients (16.7%) completing fewer than 56 days of antimicrobial treatment. Antibiotic-associated complications requiring cessation of one or more antibiotics occurred in 21 (15.9%) patients. Limited surgical debridement was performed on 30 of these medically managed patients (22.7%). Cure was achieved, with healing within 12 months, in 131 of 132 patients (99.2%), and cosmetic outcomes were excellent. Primary rifampin-based oral medical therapy for M. ulcerans disease, combined with either clarithromycin or a fluoroquinolone, has an excellent rate of cure and an acceptable toxicity profile in Australian patients. We advocate for further research to determine the optimal and safest minimum duration of medical therapy for BU.

Lessons Learned From a Randomized Controlled Trial of Short-Course Intravenous Antibiotic Therapy for Erysipelas and Cellulitis of the Lower Limb (Switch Trial).

BACKGROUND: The diagnosis of cellulitis is made clinically without a gold standard diagnostic test, and cellulitis has many disease mimics. There is currently no consensus for optimal antimicrobial treatment duration or method of antimicrobial delivery. METHODS: This was a randomized controlled open-label multicenter trial to determine the safety and efficacy of 24 hours of intravenous (IV) therapy compared with ≥72 hours of IV therapy, both followed by oral therapy to a maximum of 7-10 days' duration for the treatment of lower limb cellulitis. RESULTS: Over 40 months, 80 patients were recruited. Thirty-nine patients were assigned to 24 hours of IV antibiotics and 41 to ≥72 hours of IV antibiotics. The mean duration (range) of IV antibiotics in the 24-hour group was 25.5 (17-40) hours, and in the ≥72-hour group it was 78 (41.5-210) hours. Three patients in the 24-hour arm and 4 patients in the ≥72-hour arm were excluded from the analysis due to withdrawal from the trial. Analysis of the remaining patients revealed that 6 patients (4 in the intervention arm and 2 in the control arm) did not achieve an adequate response to therapy. Only 1 patient experienced self-limiting adverse effects of treatment. CONCLUSIONS: The noninferiority of short-course IV therapy cannot be determined from this trial. Challenges included resource limitations for recruitment, misdiagnosis, participant withdrawal, and subjective responses to therapy based on visual assessment by treating clinicians. Further studies are needed to determine if short-course IV therapy is a suitable treatment option. AUSTRALIA COUNCIL OF CLINICAL TRIALS REGISTRY NO: ACTRN12613001366741.

Continuous-infusion penicillin home-based therapy for serious infections due to penicillin-susceptible pathogens.

To evaluate the feasibility of continuous-infusion (CI) penicillin in the treatment of serious bacterial infections, consecutive adult patients with deep-seated infections due to penicillin-susceptible pathogens were treated with CI aqueous penicillin G in a home-based programme, and their treatment outcomes were reviewed. Thirty-one patients with microbiologically proven infections completed the planned course of treatment. Twenty of 31 (65%) were followed for at least 2 months thereafter, and all remained free of relapse. One patient had fever attributable to penicillin hypersensitivity, two patients developed catheter-site infections and one patient developed catheter-related bacteraemia. Thus, CI penicillin is feasible for the home-based treatment of a variety of deep-seated infections with minimal toxicity.

Cleaning, resistant bacteria, and antibiotic prescribing in residential aged care facilities.

Residents of residential aged care facilities (RACFs) are at risk of colonization and infection with multidrug-resistant bacteria, and antibiotic prescribing is often inappropriate and not based on culture-proven infection. We describe low levels of resident colonization and environmental contamination with resistant gram-negative bacteria in RACFs, but high levels of empirical antibiotic use not guided by microbiologic culture. This research highlights the importance of antimicrobial stewardship and environmental cleaning in aged care facilities.

Health care--associated bloodstream infections in adults: a reason to change the accepted definition of community-acquired infections.

BACKGROUND: Bloodstream infections occurring in persons residing in the community, regardless of whether those persons have been receiving health care in an outpatient facility, have traditionally been categorized as community-acquired infections. OBJECTIVE: To develop a new classification scheme for bloodstream infections that distinguishes among community-acquired, health care-associated, and nosocomial infections. DESIGN: Prospective observational study. SETTING: One academic medical center and two community hospitals. PATIENTS: All adult patients admitted to the hospital with bloodstream infection. MEASUREMENTS: Demographic characteristics, living arrangements before hospitalization, comorbid medical conditions, factors predisposing to bloodstream infection, date of hospitalization, dates and number of positive blood cultures, results of microbiological susceptibility testing, dates of hospital discharge or death, and mortality rates at 3 to 6 months of follow-up. RESULTS: 504 patients with bloodstream infections were enrolled; 143 (28%) had community-acquired bloodstream infections, 186 (37%) had health care-associated bloodstream infections, and 175 (35%) had nosocomial bloodstream infections. Of the 186 patients with health care-associated bloodstream infection, 29 resided in a nursing home, 64 were receiving home health care, 78 were receiving intravenous or intravascular therapy at home or in a clinic, and 117 had been hospitalized in the 90 days before their bloodstream infection. Cancer was more common in patients with health care-associated or nosocomial bloodstream infection than in patients with community-acquired bloodstream infection. Intravascular devices were the most common source of health care-associated and nosocomial infections, and Staphylococcus aureus was the most frequent pathogen in these types of infections. Methicillin-resistant S. aureus occurred with similar frequency in the groups with health care-associated infection (52%) and nosocomial infection (61%) but was uncommon in the group with community-acquired bloodstream infection (14%) (P = 0.001). Mortality rate at follow-up was greater in patients with health care-associated infection (29% versus 16%; P = 0.019) or nosocomial infection (37% versus 16%; P < 0.001) than in patients with community-acquired infection. CONCLUSIONS: Health care-associated bloodstream infections are similar to nosocomial infections in terms of frequency of various comorbid conditions, source of infection, pathogens and their susceptibility patterns, and mortality rate at follow-up. A separate category for health care-associated bloodstream infections is justified, and this new category will have obvious implications for choices about empirical therapy and infection-control surveillance.

The effectiveness of a single-stage versus traditional three-staged protocol of hospital disinfection at eradicating vancomycin-resistant Enterococci from frequently touched surfaces.

BACKGROUND: Environmental contamination is a reservoir for vancomycin-resistant enterococcus (VRE) in hospitals. METHODS: Environmental sampling of surfaces was undertaken anytime before disinfection and 1 hour after disinfection utilizing a sodium dichloroisocyanurate-based, 3-staged protocol (phase 1) or benzalkonium chloride-based, single-stage clean (phase 2). VRE colonization and infection rates are presented from 2010 to 2011, and audits of cleaning completeness were also analyzed. RESULTS: Environmental samples collected before disinfection were significantly more likely to be contaminated with VRE during phase 1 than phase 2: 25.2% versus 4.6%, respectively; odds ratio (OR), 7.01 (P < .01). Environmental samples collected after disinfection were also significantly more likely to yield VRE during phase 1 compared with phase 2: 11.2% versus 1.1%, respectively; OR, 11.73 (P < .01). Rates of VRE colonization were higher during 2010 than 2011. Cleaning audits showed similar results over both time periods. CONCLUSION: During use of a chlorine-based, 3-staged protocol, significantly higher residual levels of VRE contamination were identified, compared with levels detected during use of a benzalkonium chloride-based product for disinfection. This reduction in VRE may be due to a new disinfection product, more attention to the thoroughness of cleaning, or other supplementary efforts in our institution.