Early Infectious Diseases Specialty Intervention Is Associated With Shorter Hospital Stays and Lower Readmission Rates: A Retrospective Cohort Study.

Background: Intervention by infectious diseases (ID) physicians improves outcomes for inpatients in Medicare, but patients with other insurance types could fare differently. We assessed whether ID involvement leads to better outcomes among privately insured patients under age 65 years hospitalized with common infections. Methods: We performed a retrospective analysis of administrative claims data from community hospital and postdischarge ambulatory care. Patients were privately insured individuals less than 65 years old with an acute-care stay in 2014 for selected infections, classed as having early (by day 3) or late (after day 3) ID intervention, or none. Key outcomes were mortality, cost, length of the index stay, readmission rate, mortality, and total cost of care over the first 30 days after discharge. Results: Patients managed with early ID involvement had shorter length of stay, lower spending, and lower mortality in the index stay than those patients managed without ID involvement. Relative to late, early ID involvement was associated with shorter length of stay and lower cost. Individuals with early ID intervention during hospitalization had fewer readmissions and lower healthcare payments after discharge. Relative to late, those with early ID intervention experienced lower readmission, lower spending, and lower mortality. Conclusions: Among privately insured patients less than 65 years old, treated in a hospital, early intervention with an ID physician was associated with lower mortality rate and shorter length of stay. Patients who received early ID intervention during their hospital stay were less likely to be readmitted after discharge and had lower total healthcare spending.

Essential Resources and Strategies for Antibiotic Stewardship Programs in the Acute Care Setting.

Background: Antibiotic stewardship programs improve clinical outcomes and patient safety and help combat antibiotic resistance. Specific guidance on resources needed to structure stewardship programs is lacking. This manuscript describes results of a survey of US stewardship programs and resultant recommendations regarding potential staffing structures in the acute care setting. Methods: A cross-sectional survey of members of 3 infectious diseases subspecialty societies actively involved in antibiotic stewardship was conducted. Survey responses were analyzed with descriptive statistics. Logistic regression models were used to investigate the relationship between stewardship program staffing levels and self-reported effectiveness and to determine which strategies mediate effectiveness. Results: Two-hundred forty-four respondents from a variety of acute care settings completed the survey. Prior authorization for select antibiotics, antibiotic reviews with prospective audit and feedback, and guideline development were common strategies. Eighty-five percent of surveyed programs demonstrated effectiveness in at least 1 outcome in the prior 2 years. Each 0.50 increase in pharmacist and physician full-time equivalent (FTE) support predicted a 1.48-fold increase in the odds of demonstrating effectiveness. The effect was mediated by the ability to perform prospective audit and feedback. Most programs noted significant barriers to success. Conclusions: Based on our survey's results, we propose an FTE-to-bed ratio that can be used as a starting point to guide discussions regarding necessary resources for antibiotic stewardship programs with executive leadership. Prospective audit and feedback should be the cornerstone of stewardship programs, and both physician leadership and pharmacists with expertise in stewardship are crucial for success.

Tedizolid: The First Once-Daily Oxazolidinone Class Antibiotic.

Tedizolid phosphate is the second commercially available oxazolidinone antibiotic, although the first one in class that is dosed once daily. It is a prodrug that is rapidly converted to the active compound tedizolid. Tedizolid has activity against a wide range of gram-positive pathogens, including methicillin-resistant Staphylococcus aureus. It is approved to treat acute bacterial skin and skin structure infections (ABSSSIs). In 2 randomized controlled phase 3 trials, 6 days of tedizolid (200 mg once daily) has been proven to be noninferior to 10 days of linezolid (600 mg twice daily). These 2 ABSSSI studies have positioned tedizolid among the growing armamentarium of newer, novel, anti-gram-positive agents. Tedizolid appears to differ from linezolid in the incidence of gastrointestinal and hematologic side effects and appears to lack drug interactions with selective serotonin reuptake inhibitors. Conditions other than ABSSSI are currently being evaluated in clinical studies.

Histoplasmosis complicating tumor necrosis factor-α blocker therapy: a retrospective analysis of 98 cases.

BACKGROUND: Histoplasmosis may complicate tumor necrosis factor (TNF)-α blocker therapy. Published case series provide limited guidance on disease management. We sought to determine the need for long-term antifungal therapy and the safety of resuming TNF-α blocker therapy after successful treatment of histoplasmosis. METHODS: We conducted a multicenter retrospective review of 98 patients diagnosed with histoplasmosis between January 2000 and June 2011. Multivariate logistic regression was used to evaluate risk factors for severe disease. RESULTS: The most commonly used biologic agent was infliximab (67.3%). Concomitant corticosteroid use (odds ratio [OR], 3.94 [95% confidence interval {CI}, 1.06-14.60]) and higher urine Histoplasma antigen levels (OR, 1.14 [95% CI, 1.03-1.25]) were found to be independent predictors of severe disease. Forty-six (47.4%) patients were initially treated with an amphotericin B formulation for a median duration of 2 weeks. Azole treatment was given for a median of 12 months. TNF-α blocker therapy was initially discontinued in 95 of 98 (96.9%) patients and later resumed in 25 of 74 (33.8%) patients at a median of 12 months (range, 1-69 months). The recurrence rate was 3.2% at a median follow-up period of 32 months. Of the 3 patients with recurrence, 2 had restarted TNF-α blocker therapy, 1 of whom died. Mortality rate was 3.2%. CONCLUSIONS: In this study, disease outcomes were generally favorable. Discontinuation of antifungal treatment after clinical response and an appropriate duration of therapy, probably at least 12 months, appears safe if pharmacologic immunosuppression has been held. Resumption of TNF-α blocker therapy also appears safe, assuming that the initial antifungal therapy was administered for 12 months.

Histoplasmosis after solid organ transplant.

BACKGROUND: To improve our understanding of risk factors, management, diagnosis, and outcomes associated with histoplasmosis after solid organ transplant (SOT), we report a large series of histoplasmosis occurring after SOT. METHODS: All cases of histoplasmosis in SOT recipients diagnosed between 1 January 2003 and 31 December 2010 at 24 institutions were identified. Demographic, clinical, and laboratory data were collected. RESULTS: One hundred fifty-two cases were identified: kidney (51%), liver (16%), kidney/pancreas (14%), heart (9%), lung (5%), pancreas (2%), and other (2%). The median time from transplant to diagnosis was 27 months, but 34% were diagnosed in the first year after transplant. Twenty-eight percent of patients had severe disease (requiring intensive care unit admission); 81% had disseminated disease. Urine Histoplasma antigen detection was the most sensitive diagnostic method, positive in 132 of 142 patients (93%). An amphotericin formulation was administered initially to 73% of patients for a median duration of 2 weeks; step-down therapy with an azole was continued for a median duration of 12 months. Ten percent of patients died due to histoplasmosis with 72% of deaths occurring in the first month after diagnosis; older age and severe disease were risk factors for death from histoplasmosis. Relapse occurred in 6% of patients. CONCLUSIONS: Although late cases occur, the first year after SOT is the period of highest risk for histoplasmosis. In patients who survive the first month after diagnosis, treatment with an amphotericin formulation followed by an azole for 12 months is usually successful, with only rare relapse.

Use of single agent Cefotetan for Gustilo-Anderson type III open fracture prophylaxis.

INTRODUCTION: The prophylactic intravenous antibiotic regimen for Gustilo-Anderson Type III open fractures traditionally consists of cefazolin with an aminoglycoside plus penicillin for gross contamination. Cefotetan, a second-generation cephalosporin, offers a wide spectrum of activity against both aerobes and anaerobes as well as against Gram-positive and Gram-negative bacteria. Cefotetan has not been previously established within orthopedic surgery as a prophylactic intravenous agent. PATIENTS AND METHODS: Cefotetan monotherapeutic prophylaxis versus any other antibiotic regimen (standard/literature-supported and otherwise) was studied for patient encounters between September 2010 and December 2019 within a single Level 1 regional trauma center. Patient comorbidities, preoperative fracture characteristics, and in-hospital/operative metrics (including length of stay [LOS], number of antibiotic doses, and antibiotic costs [US$]) were included for analysis. Postoperative outcomes up to 1 year included rates of surgical site infection (SSI), deep infection necessitating return to the operating room (OR), non-union, prescribed outpatient antibiotics, hospital readmissions, and related returns to the emergency department (ED). Sensitivity analyses were also conducted to include standard/literature-supported antibiotic regimens as a nested random factor within the non-cefotetan cohort. RESULTS: The nested variable accounting for standard/literature-supported antibiotic regimens had no significant effect in any model for any outcome (for each, P ≥ 0.302). Thus, 1-year data for 138 Type III open fractures were included, accounting for only the binary effect of cefotetan (n = 42) versus non-cefotetan cohorts. The cohorts did not differ significantly at baseline. The cefotetan cohort received fewer in-house dose/day antibiotics (P < 0.001), was less likely to receive outpatient antibiotics in the following year (P = 0.023), had decreased return to the OR (35.7% versus 54.2%, P = 0.045), and demonstrated non-union rates of 16.7% versus 28.1% (P = 0.151). When adjusted for length of stay (LOS), the dose/day total costs for antibiotics were $8.71/day more expensive for the cefotetan cohort (P = 0.002). Type III open fractures incurred overall rates of SSI reaching 16.7% in the cefotetan cohort and 14.7% for non-cefotetan (P = 0.773). Deep infections necessitating return to the OR were 9.5% and 11.6%, respectively (P = 0.719). CONCLUSION: Cefotetan alone may provide superior antibiotic stewardship with similar infectious sequalae compared to more traditional antibiotic prophylaxis regimens for Gustilo-Anderson Type III open long bone fractures. LEVEL OF EVIDENCE: Level III Retrospective Cohort Study.

Mobile infectious disease references: from the bedside to the beach.

Point-of-care access to current medical information is easily available to the practitioner through the use of smartphones, iPads, and other personal digital assistants. There are numerous mobile applications (apps) that provide easy-to-use and often well-referenced medical guidance for the infectious diseases practitioner. We reviewed 6 commonly utilized mobile apps available for handheld devices: the Emergency Medicine Residents' Association's (EMRA's) Antibiotic Guide, Epocrates Deluxe, Johns Hopkins Antibiotic Guide, Sanford Guide, the Medscape mobile app, and the Infectious Diseases Compendium. We evaluated several basic infectious diseases topics (including but not limited to endocarditis, vancomycin, and Acinetobacter infection) and attempted to objectively score them for metrics that would help the provider determine which mobile app would be most useful for his or her practice. The Johns Hopkins Antibiotic Guide and the Sanford Guide had the highest cumulative scores, whereas EMRA scored the lowest. We found that no single app will meet all of the needs of an infectious diseases physician. Each app delivers content in a unique way and would meet divergent needs for all practitioners, from the experienced clinician to the trainee. The ability to rapidly access trusted medical knowledge at the point of care can help all healthcare providers better treat their patients' infections.

Surfing the web: practicing medicine in a technological age: using smartphones in clinical practice.

Mobile technology has the potential to revolutionize how physicians practice medicine. From having access to the latest medical research at the point of care to being able to communicate at a moment's notice with physicians and colleagues around the world, we are practicing medicine in a technological age. During recent years, many physicians have been simultaneously using a pager, cellular telephone, and personal digital assistant (PDA) to keep in communication with the hospital and to access medical information or calendar functions. Many physicians have begun replacing multiple devices with a "smartphone," which functions as a cellular telephone, pager, and PDA. The goal of this article is to provide an overview of the currently available platforms that make up the smartphone devices and the available medical software. Each platform has its unique advantages and disadvantages, and available software will vary by device and is in constant flux.

DISC: Describing Infections of the Spine treated with Ceftaroline.

OBJECTIVES: Infections of the spine lead to considerable morbidity and a high cost to the global healthcare system. Currently, evidence for using ceftaroline, an advanced-generation cephalosporin active against methicillin-resistant Staphylococcus aureus (MRSA), in spine infections is limited. METHODS: Describing Infections of the Spine treated with Ceftaroline (DISC) is a multicentre, retrospective, cohort study that evaluated ceftaroline for treating spine infections. Patients were included if they were aged ≥18 years, diagnosed with a spine infection and treated with ceftaroline for ≥28 days. A control group was identified with the same inclusion criteria as the study population except they were treated with a comparator antibiotic for ≥28 days. RESULTS: Thirty-seven patients were included each in the ceftaroline and control groups. MRSA was the most commonly identified pathogen. With no differences between groups in age, sex, race or co-morbidities (with the exception of chronic kidney disease), treatment with ceftaroline led to similar clinical success compared with the control group. Multivariate regression analysis did not show a significant difference between the two groups in terms of clinical success after controlling for other covariates (adjusted odds ratio=1.49; P=0.711). More patients who received ceftaroline were discharged to an extended-care or rehabilitation facility than home compared with controls (81% vs. 54%, respectively; P=0.024). Side effects and toxicities were rare, including one case of eosinophilic pneumonia in the ceftaroline group. CONCLUSIONS: Ceftaroline appears to be a safe and effective therapy for infections of the spine, including from MRSA.

Electronic tools for infectious diseases and microbiology.

Electronic tools for infectious diseases and medical microbiology have the ability to change the way the diagnosis and treatment of infectious diseases are approached. Medical information today has the ability to be dynamic, keeping up with the latest research or clinical issues, instead of being static and years behind, as many textbooks are. The ability to rapidly disseminate information around the world opens up the possibility of communicating with people thousands of miles away to quickly and efficiently learn about emerging infections. Electronic tools have expanded beyond the desktop computer and the Internet, and now include personal digital assistants and other portable devices such as cellular phones. These pocket-sized devices have the ability to provide access to clinical information at the point of care. New electronic tools include e-mail listservs, electronic drug databases and search engines that allow focused clinical questions. The goal of the present article is to provide an overview of how electronic tools can impact infectious diseases and microbiology, while providing links and resources to allow users to maximize their efficiency in accessing this information. Links to the mentioned Web sites and programs are provided along with other useful electronic tools.

Antimicrobe.org: an online reference for the practicing infectious diseases specialist.

Antimicrobe.org (http://www.antimicrobe.org) is a World Wide Web-based version of the textbook Antimicrobial Therapy and Vaccines, volumes I and II. The Web site currently consists of 3 texts (Microbes, Antimicrobial Agents, and HIV Clinical Manual) and will soon include a fourth, Empiric. The Web site focuses on therapy for infectious diseases, and it covers, in comprehensive detail, a great majority of infections encountered today. The dynamic nature of a Web-based reference allows for information to be frequently updated and enhances a physician's searching capabilities to find answers to very specific clinical questions and the latest available evidence. A Smart Search engine allows users to ask specific questions and to find focused answers, either within the textbook or through PubMed via a guided PubMed references option. The Web site also provides clinical vignettes and minireviews on hot topics in infectious diseases and hyperlinks to other important articles or Web sites. Chapters are written by experts in their field who provide evidence-based information, as well as anecdotal reports about rare infections. Antimicrobe.org would be of great benefit to physicians who treat infections on a routine basis.

Bite the hand that sprays you.

A 56-year-old man presented with a cutaneous lesion on his right hand (Figure 1). Approximately 6 weeks previously, he had traveled to Costa Rica for missionary work. During his travel he used a diethyltoluamide-containing insect repellant, but spent one night in the jungle without a mosquito net. Four weeks after his return, he noted a 3 x 2.5-cm ulcer with raised edges and surrounding erythema on the dorsum of his right hand. The patient recalled applying insect repellant with his right hand to other exposed areas of his body but was remiss in applying it to the right hand itself. On examination, the patient was noted to have an ulcerated nodule near his right earlobe (Figure 2) and a second 2 x 1-cm ulcer on the volar aspect of his right wrist (Figure 3). There were no mucocutaneous lesions noted. During the next several weeks, numerous nodules developed in a sporotrichoid pattern on the extensor surface of his right arm (Figure 4). Skin biopsy was performed at the time of initial evaluation and revealed cutaneous leishmaniasis due to Leishmania panamensis. After discussing the different treatment options, miltefosine was administered orally for 28 days. The patient experienced an excellent response to therapy.

Intestinal invasion and disseminated disease associated with Penicillium chrysogenum.

BACKGROUND: Penicillium sp., other than P. marneffei, is an unusual cause of invasive disease. These organisms are often identified in immunosuppressed patients, either due to human immunodeficiency virus or from immunosuppressant medications post-transplantation. They are a rarely identified cause of infection in immunocompetent hosts. CASE PRESENTATION: A 51 year old African-American female presented with an acute abdomen and underwent an exploratory laparotomy which revealed an incarcerated peristomal hernia. Her postoperative course was complicated by severe sepsis syndrome with respiratory failure, hypotension, leukocytosis, and DIC. On postoperative day 9 she was found to have an anastamotic breakdown. Pathology from the second surgery showed transmural ischemic necrosis with angioinvasion of a fungal organism. Fungal blood cultures were positive for Penicillium chrysogenum and the patient completed a 6 week course of amphotericin B lipid complex, followed by an extended course oral intraconazole. She was discharged to a nursing home without evidence of recurrent infection. DISCUSSION: Penicillium chrysogenum is a rare cause of infection in immunocompetent patients. Diagnosis can be difficult, but Penicillium sp. grows rapidly on routine fungal cultures. Prognosis remains very poor, but aggressive treatment is essential, including surgical debridement and the removal of foci of infection along with the use of amphotericin B. The clinical utility of newer antifungal agents remains to be determined.

The gift that keeps on giving.

Case 1: A 39-year-old man with chronic lower extremity lymphedema was admitted to the hospital with acute fever, chills, and left lower extremity pain, swelling, and erythema for the third time in as many months. Examination revealed a temperature of 39 degrees C (102.2 degrees F), and erythmatous induration on the left leg (Figure). The patient was treated with IV clindamycin and cefazolin, with clinical improvement. He was discharged with azithromycin, 500 mg daily for 3 days, done twice monthly. Case 2: A 52-year-old morbidly obese man with stasis dermatitis presented with acute lower extremity pain, swelling, and associated fever. He had been taking prophylactic antibiotics for his recurrent cellulitis for more than a decade and had significantly decreased his number of reoccurrences while on this therapy. He was admitted to the hospital, treated with IV cefazolin, and had a rapid improvement over 48 hours. He was subsequently discharged with continued suppressive antibiotic therapy.

With this eruption, there is not a second to lues.

A 28-year-old white man presented to the Emergency Department with a 24-hour history of an eruption on his extremities, trunk, and face. The patient was known to be HIV positive with a CD4 count of 527 and a viral load of 20,300. He denied fever, chills, malaise, and headache. His social history was significant for the fact that he was in a monogamous homosexual relationship. He had no recent travel, pet exposures, or sick contacts. Physical examination revealed stable vital signs and no documented fever. A maculopapular eruption was present on his face, trunk, and extremities (Figures 1 and 2). There was no palmar or plantar involvement. He was treated with diphenhydramine and topical 2.5% hydrocortisone and advised to return if his condition did not improve. Twelve days after the initial evaluation, the patient consulted us again due to progression of his dermatitis. He had no additional complaints other than an eruption on both palms but neither sole. (Figure 3). The eruption now demonstrated erythematous pink-red oval macules and papules 1-2 cm in size distributed on his scalp, face, trunk, and arms. A few papules contained fine collarettes of scale. Further questioning revealed that the patient had experienced a tender rectal ulcer 2 months previously. A punch biopsy and rapid plasma reagin were performed. The histopathologic examination revealed interface dermatitis with lymphocytes, plasma cells, occasional neutrophils, and a prominent lymphoplasmacytic perivascular dermatitis with infiltration of the vessel walls. Warthrin-Starry and Steiner methods demonstrated spirochetes at the dermal-epidermal junction and in vessel walls, consistent with Treponema pallidum (Figure 4). Rapid plasma reagin and fluorescent Treponema antibody were both reactive with a Venereal Disease Research Laboratory (VDRL) of 1:16. The patient was diagnosed as having secondary syphilis and treated with 2.4 million units of IM benzathine penicillin for 3 weeks. His eruption resolved after the initial treatment and he did not experience a Jarisch-Herxheimer reaction.

Killing Bugs at the Bedside: a prospective hospital survey of how frequently personal digital assistants provide expert recommendations in the treatment of infectious diseases.

BACKGROUND: Personal Digital Assistants (PDAS) are rapidly becoming popular tools in the assistance of managing hospitalized patients, but little is known about how often expert recommendations are available for the treatment of infectious diseases in hospitalized patients. OBJECTIVE: To determine how often PDAs could provide expert recommendations for the management of infectious diseases in patients admitted to a general medicine teaching service. DESIGN: Prospective observational cohort study SETTING: Internal medicine resident teaching service at an urban hospital in Dayton, Ohio PATIENTS: 212 patients (out of 883 patients screened) were identified with possible infectious etiologies as the cause for admission to the hospital. MEASUREMENTS: Patients were screened prospectively from July 2002 until October 2002 for infectious conditions as the cause of their admissions. 5 PDA programs were assessed in October 2002 to see if treatment recommendations were available for managing these patients. The programs were then reassessed in January 2004 to evaluate how the latest editions of the software would perform under the same context as the previous year. RESULTS: PDAs provided treatment recommendations in at least one of the programs for 100% of the patients admitted over the 4 month period in the 2004 evaluation. Each of the programs reviewed improved from 2002 to 2004, with five of the six programs offering treatment recommendations for over 90% of patients in the study. CONCLUSION: Current PDA software provides expert recommendations for a great majority of general internal medicine patients presenting to the hospital with infectious conditions.

Infectious disease capsules: a pox on your house.

A 31-year-old, previously healthy white man presented to the emergency department with complaints of malaise, fevers, shortness of breath, a non-productive cough, and a "rash." His physical exam revealed a temperature of 100.2F, a pulse of 129 bpm, respiratory rate of 14 BPM, and blood pressure of 140/74 mm Hg. He was alert, oriented, and in no distress. His oropharynx was dry, his neck was supple, and cervical lymphadenopathy was absent. He had tachycardia, bilateral wheezes, and rhonchi with prolonged expirations. There was a diffuse vesicular eruption enveloping his entire body with involvement sparing his palms and soles (Figures 1 and 2). Laboratory values showed a hemoglobin of 16.0 g/dL and a white blood cell count of 7100 cells/pL, with 39%neutrophils, 23% bands, and 35% lymphocytes. His platelet count was mildly decreased to 86,000 x 103/pL. Chest radiograph revealed bilateral diffuse interstitial infiltrates. A diagnosis of acute varicella-zoster virus pneumonia (varicella pneumonia) was made, and the patient was started on IV acyclovir (10 mg/kg every 8 hours). Upon further questioning, the patient stated that his daughter had been diagnosed with "chickenpox" 7 days ago. The patient had numerous exposures to chickenpox in the past but had never developed clinical expressions of varicella. He was not at risk for HIV infection, not having multiple sexual partners, IV drug abuse, or blood transfusions. During the 1 day of in-hospitalization, his fever abated and the pulmonary signs diminished. Following discharge, IV acyclovir was replaced by valacyclovir to complete a 7-day course of therapy.

Dosing strategy to allow continued therapy with daptomycin after asymptomatic increases in creatine kinase levels.

PURPOSE: A case series in which a novel dosing strategy for managing mild, asymptomatic creatine kinase (CK) increases associated with daptomycin therapy is presented. SUMMARY: Eight patients received a mean daptomycin dosage of 7.75 mg/kg/day for a median duration of 42 days. Seven of the eight patients were being treated for a bone and joint infection, and all but one had methicillin-resistant Staphylococcus aureus. All patients had asymptomatic increases in CK concentrations during daptomycin therapy (peak range, 400-1200 IU/L). A single daptomycin dose was withheld from each patient, and therapy was resumed 24 hours later, most often at the same dosage. The elevated CK values in these patients resolved, and all patients were able to complete daptomycin therapy without further increases in CK elevations. These findings indicate that withholding one dose of daptomycin during treatment may allow patients with asymptomatic, elevated CK concentrations to continue therapy with CK level normalization. Although the mechanism of daptomycin-mediated muscle injury is not fully understood, a reduction in daptomycin exposure via a one-dose cessation of therapy may allow for physiological restoration of sarcolemma membrane integrity that may be disrupted by daptomycin in individuals exhibiting CK elevation. CONCLUSION: A single daptomycin dose was withheld from eight patients with asymptomatic increases in serum CK concentrations, then daptomycin therapy was resumed 24 hours later, most often at the previous dosage. The CK concentrations returned to normal, and all patients were able to complete daptomycin therapy without further increases in CK concentrations.