Eravacycline infusion-related hypoesthesia: A case report.

PURPOSE: Eravacycline (ERV) is often used for drug-resistant gram-negative and nontuberculous mycobacteria (NTM) infections, but infusion site reactions are a potential adverse effect. We report a case of severe hypoesthesia secondary to ERV infusion. SUMMARY: A 74-year-old man presented with dyspnea, shortness of breath, and hemoptysis after being treated for community-acquired pneumonia. On the basis of respiratory cultures performed several weeks before the index hospitalization, he was diagnosed with Mycobacterium chelonae pneumonia. On hospital day (HD) 2, the infectious diseases consult team, guided by susceptibilities, initiated a regimen of azithromycin, levofloxacin, and ERV 80 mg (1 mg/kg) intravenously every 12 hours infused over 1 hour in 250 mL of normal saline. Approximately 25 minutes after the ERV infusion began, the patient reported tingling and numbness in his fingers, hands, and mouth, with shooting pain in his head. Symptoms resolved with cessation of the ERV infusion. On HD 3, the same ERV dose and volume was administered with an extended infusion time of 2 hours. The patient experienced the same reaction after 58 minutes, which ceased shortly after the infusion was stopped. Use of ERV was subsequently discontinued. The Naranjo adverse drug reaction probability scale score was 9, indicating a definite reaction. A review of the Food and Drug Administration Adverse Event Reporting System through March 2021 identified 22 ERV-associated events. Among these, 18% appear to be related to ERV infusions. Published results from phase 3 clinical trials did not document any hypoesthesia. It is unknown whether there is a correlation between concentration, dose, or infusion time and associated reactions. CONCLUSION: This is a unique case of severe hypoesthesia secondary to ERV infusion leading to drug discontinuation. More data are needed to determine effective mitigation strategies.

Application of Standardized Antimicrobial Administration Ratio as a Motivational Tool within a Multi-Hospital Healthcare System.

The standardized antimicrobial administration ratio (SAAR) is a novel antimicrobial stewardship metric that compares actual to expected antimicrobial use (AU). This prospective cohort study examines the utility of SAAR reporting and inter-facility comparisons as a motivational tool to improve overall and broad-spectrum AU within a three-hospital healthcare system. Transparent inter-facility comparisons were deployed during system-wide antimicrobial stewardship meetings beginning in October 2017. Stakeholders were advised to interpret the results to foster competition and incorporate SAAR data into focused antimicrobial stewardship interventions. Student's t-test was used to compare mean SAARs in the pre- (July 2017 through October 2017) and post-intervention periods (November 2017 through June 2019). The mean pre-intervention SAARs for hospitals A, B, and C were 0.69, 1.09, and 0.60, respectively. Hospital B experienced significant reductions in SAAR for overall AU (from 1.09 to 0.83; p < 0.001), broad-spectrum antimicrobials used for hospital-onset infections (from 1.36 to 0.81; p < 0.001), and agents used for resistant gram-positive infections in the intensive care units (from 1.27 to 0.72; p < 0.001) after the interventions. The alignment of the SAAR across the health-system and sustained reduction in overall and broad-spectrum AU through implementation of inter-facility comparisons demonstrate the utility in the motivational application of this antimicrobial use metric.

Opportunities and challenges in improving antimicrobial use during the era of telehealth expansion: A narrative review.

Efforts to improve antimicrobial prescribing are occurring within a changing healthcare landscape, which includes the expanded use of telehealth technology. The wider adoption of telehealth presents both challenges and opportunities for promoting antimicrobial stewardship. Telehealth provides 2 avenues for remote infectious disease (ID) specialists to improve inpatient antimicrobial prescribing: telehealth-supported antimicrobial stewardship and tele-ID consultations. Those 2 activities can work separately or synergistically. Studies on telehealth-supported antimicrobial stewardship have reported a reduction in inpatient antimicrobial prescribing, cost savings related to less antimicrobial use, a decrease in Clostridioides difficile infections, and improved antimicrobial susceptibility patterns for common organisms. Tele-ID consultation is associated with fewer hospital transfers, a shorter length of hospital stay, and decreased mortality. The implementation of these activities can be flexible depending on local needs and available resources, but several barriers may be encountered. Opportunities also exist to improve antimicrobial use in outpatient settings. Telehealth provides a more rapid mechanism for conducting outpatient ID consultations, and increasing use of telehealth for routine and urgent outpatient visits present new challenges for antimicrobial stewardship. In primary care, urgent care, and emergency care settings, unnecessary antimicrobial use for viral acute respiratory tract infections is common during telehealth encounters, as is the case for fact-to-face encounters. For some diagnoses, such as otitis media and pharyngitis, antimicrobials are further overprescribed via telehealth. Evidence is still lacking on the optimal stewardship strategies to improve antimicrobial prescribing during telehealth encounters in ambulatory care, but conventional outpatient stewardship strategies are likely transferable. Further work is warranted to fill this knowledge gap.

The Mbeya Antimicrobial Stewardship Team: Implementing Antimicrobial Stewardship at a Zonal-Level Hospital in Southern Tanzania.

Background: In 2017, Mbeya Zonal Referral Hospital (MZRH) and the University of South Carolina (UofSC) agreed to collaboratively strengthen antimicrobial prescribing in the southern highlands of Tanzania and train a new generation of clinicians in responsible antimicrobial use. Methods: Key stakeholders and participants were identified and the Mbeya Antimicrobial Stewardship Team (MAST) was created. The team identified assets brought by the collaborators, and four investigations of baseline needs were developed. These investigations included (a) a baseline clinician survey regarding antimicrobial resistance and stewardship, (b) a serial chart review of inpatient antimicrobial prescribing practices, (c) an investigation of antimicrobial resistance rates using existing isolates at the MZRH laboratory, and (d) a survey of antimicrobial availability at community pharmacies in the city. Results: 91% of physicians believe antimicrobial resistance is problem in Tanzania, although only 29% of physicians were familiar with the term "antimicrobial stewardship". Escherichia coli isolates had resistance rates of over 60% to the commonly used agents ciprofloxacin, trimethoprim-sulfamethoxazole, and ceftriaxone. Thirteen out of 14 community pharmacies offered over-the-counter antibiotics for upper respiratory symptoms. Conclusions: International antimicrobial stewardship collaborations can successfully identify opportunities and needs. Evaluating the team's efforts to improve patient outcomes will be essential.

Impact of Reappraisal of Fluoroquinolone Minimum Inhibitory Concentration Susceptibility Breakpoints in Gram-Negative Bloodstream Isolates.

The Clinical Laboratory Standards Institute lowered the fluoroquinolone minimum inhibitory concentration (MIC) susceptibility breakpoints for Enterobacteriaceae and glucose non-fermenting Gram-negative bacilli in January 2019. This retrospective cohort study describes the impact of this reappraisal on ciprofloxacin susceptibility overall and in patients with risk factors for antimicrobial resistance. Gram-negative bloodstream isolates collected from hospitalized adults at Prisma Health-Midlands hospitals in South Carolina, USA, from January 2010 to December 2014 were included. Matched pairs mean difference (MD) with 95% confidence intervals (CI) were calculated to examine the change in ciprofloxacin susceptibility after MIC breakpoint reappraisal. Susceptibility of Enterobacteriaceae to ciprofloxacin declined by 5.2% (95% CI: -6.6, -3.8; p < 0.001) after reappraisal. The largest impact was demonstrated among Pseudomonas aeruginosa bloodstream isolates (MD -7.8, 95% CI: -14.6, -1.1; p = 0.02) despite more conservative revision in ciprofloxacin MIC breakpoints. Among antimicrobial resistance risk factors, fluoroquinolone exposure within the previous 90 days was associated with the largest change in ciprofloxacin susceptibility (MD -9.3, 95% CI: -16.1, -2.6; p = 0.007). Reappraisal of fluoroquinolone MIC breakpoints has a variable impact on the susceptibility of bloodstream isolates by microbiology and patient population. Healthcare systems should be vigilant to systematically adopt this updated recommendation in order to optimize antimicrobial therapy in patients with bloodstream and other serious infections.

Pharmacist-Driven Culture and Sexually Transmitted Infection Testing Follow-Up Program in the Emergency Department.

Expanding pharmacist-driven antimicrobial stewardship efforts in the emergency department (ED) can improve antibiotic management for both admitted and discharged patients. We piloted a pharmacist-driven culture and rapid diagnostic technology (RDT) follow-up program in patients discharged from the ED. This was a single-center, pre- and post-implementation, cohort study examining the impact of a pharmacist-driven culture/RDT follow-up program in the ED. Adult patients discharged from the ED with subsequent positive cultures and/or RDT during the pre- (21 August 2018-18 November 2018) and post-implementation (19 November 2018-15 February 2019) periods were screened for inclusion. The primary endpoints were time from ED discharge to culture/RDT review and completion of follow-up. Secondary endpoints included antimicrobial agent prescribed during outpatient follow-up, repeat ED encounters within 30 days, and hospital admissions within 30 days. Baseline characteristics were analyzed using descriptive statistics. Time-to-event data were analyzed using the Wilcoxon signed-rank test. One-hundred-and-twenty-seven patients were included, 64 in the pre-implementation group and 63 in the post-implementation group. There was a 36.3% reduction in the meantime to culture/RDT data review in the post-implementation group (75.2 h vs. 47.9 h, p < 0.001). There was a significant reduction in fluoroquinolone prescribing in the post-implementation group (18.1% vs. 5.4%, p = 0.036). The proportion of patients who had a repeat ED encounter or hospital admission within 30 days was not significantly different between the pre- and post-implementation groups (15.6 vs. 19.1%, p = 0.78 and 9.4% vs. 7.9%, p = 1.0, respectively). Introduction of a pharmacist culture and RDT follow-up program in the ED reduced time to data review, time to outpatient intervention and outpatient follow-up of fluoroquinolone prescribing.

Assessment of a Faculty and Preceptor Development Intervention to Foster Self-Awareness and Self-Confidence.

Objective. To conduct and evaluate the outcomes of a pharmacy faculty and preceptor development program to foster self-awareness and self-confidence. Methods. A faculty and preceptor development intervention was implemented in a multi-campus college of pharmacy to promote and assess for improvements in self-awareness and self-confidence. Faculty members and preceptors were surveyed regarding their self-perceptions and confidence at baseline and following an intervention in which they completed the Birkman Method self-assessment and participated in a training program with an active-learning component. A longitudinal follow-up survey was conducted to assess the long-term impacts of the intervention. Results. Faculty members and preceptors experienced significant improvements in self-awareness from baseline following the development intervention. They also experienced increases in self-confidence related to coaching. A survey evaluating the longitudinal impact of the intervention indicated a positive association between receiving a sufficient level of Birkman Method training and improved ability of both faculty members and preceptors to manage professional relationships. Similarly, a positive association was identified between the sufficiency of training and preceptors' confidence in their ability to manage personal relationships and stress following the intervention. Conclusion. Faculty members and preceptors teach students to be more self-aware and confident, yet both groups often need to grow in these areas themselves. A faculty and preceptor development intervention using the Birkman Method self-assessment is one approach to facilitating growth in these educators' self-awareness and self-confidence.

Locomotor Training in the Pediatric Spinal Cord Injury Population: A Systematic Review of the Literature.

Background: The restoration of walking ability in the spinal cord injury (SCI) population is an increasingly important goal in physical therapy. Locomotor training (LT) is often implemented with the aim to restore ambulation. At this point, there are no guidelines for LT in the pediatric SCI population. Objectives: The aim of this review is to further narrow the effects of LT to the pediatric SCI population and develop recommendations for pediatric LT. Methods: A thorough search was performed using the following databases: Scopus, CINAHL, PubMed, and Ovid. Studies were selected based on the following inclusion criteria: pediatric SCI population, articles published within last 10 years, human subjects, and LT. Studies looking at other neurological disorders and subjects who were not previously ambulatory were excluded. Five students and one Faculty Research Advisor from the university's Doctor of Physical Therapy Program evaluated the inclusion criteria, conducted a risk of bias assessment using the Downs and Black checklist, and extracted the results. Results: Six studies were selected for this review. They showed gains in distance, gait speed, walking independence, and participation. There were variations in results when comparing gains in injury level based on the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI). Conclusions: Currently there is insufficient evidence to determine the best clinical practice guidelines for rehabilitation using LT within the pediatric SCI population.

Another look at paradoxical severity effects in head injury with the Personality Assessment Inventory.

Previous investigations of psychiatric symptomatology after head injury using the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989) have consistently revealed greater Basic scale elevations in mild injuries versus more severe injuries. In this study, we tested this pattern of paradoxical severity effects using the Personality Assessment Inventory (PAI; Morey, 1991). We gathered PAI and MMPI-2 data from 34 patients with moderate-to-severe head injuries and from 52 patients with mild head injuries. MMPI-2 Basic scale profiles were consistent with the paradoxical severity effect; mild injury patients had significantly more elevated scores on four Basic scales (Scales 1, 2, 3, and 7). PAI Clinical scale profiles showed significantly more elevated scores among mild injury patients on 2 scales, Somatization and Depression, and more elevated scores among moderate-to-severe patients on 2 scales, Antisocial Features and Alcohol Problems. We consider unique contributions of the PAI for the psychological assessment of head injury.

Homer proteins regulate sensitivity to cocaine.

Drug addiction involves complex interactions between pharmacology and learning in genetically susceptible individuals. Members of the Homer gene family are regulated by acute and chronic cocaine administration. Here, we report that deletion of Homer1 or Homer2 in mice caused the same increase in sensitivity to cocaine-induced locomotion, conditioned reward, and augmented extracellular glutamate in nucleus accumbens as that elicited by withdrawal from repeated cocaine administration. Moreover, adeno-associated virus-mediated restoration of Homer2 in the accumbens of Homer2 KO mice reversed the cocaine-sensitized phenotype. Further analysis of Homer2 KO mice revealed extensive additional behavioral and neurochemical similarities to cocaine-sensitized animals, including accelerated acquisition of cocaine self-administration and altered regulation of glutamate by metabotropic glutamate receptors and cystine/glutamate exchange. These data show that Homer deletion mimics the behavioral and neurochemical phenotype produced by repeated cocaine administration and implicate Homer in regulating addiction to cocaine.