Taurolidine and Heparin as Catheter Lock Solution for Central Venous Catheters in Hemodialysis.

BACKGROUND: Chronic kidney disease can lead to end-stage renal disease, and the prevalence is increasing. Many patients starting hemodialysis require central venous catheters (CVCs). Catheter-related bloodstream infections (CRBSIs) are a common complication and lead to significant morbidity and mortality. Interventions to prevent CRBSI include antimicrobial lock therapy but concern for the development of antimicrobial resistance and adverse effects. Nonantimicrobial antiseptics as catheter lock solutions have also been used. Taurolidine and heparin catheter lock solution is first approved by the Food and Drug Administration for the prevention of CRBSI in patients on hemodialysis. Taurolidine has a unique mechanism of action and favorable safety profile. MECHANISM OF ACTION, PHARMACODYNAMICS, AND PHARMACOKINETICS: Taurolidine and heparin catheter lock solution have both antimicrobial and anticoagulant properties. Taurolidine is derivative of the amino acid taurine, and heparin is derived from porcine intestinal mucosa. Taurolidine not only damages microbial cell walls but also prevents the adherence of microorganisms to biological surfaces, preventing biofilm formation. Taurolidine and heparin catheter lock solution is intended to be used intraluminally within the catheter and should be aspirated. Because it is used locally, limited pharmacokinetic and pharmacodynamic data are available. CLINICAL TRIALS: The LOCK-IT-100 trial is a randomized, double-blind, phase 3 study, which included 795 end-stage renal disease patients on hemodialysis with CVC. Taurolidine and heparin was compared with the control heparin alone. The results of the study showed a 71% risk reduction in CRBSI for taurolidine and heparin arm (95% confident interval, 38%-86%, P = 0.0006). Other studies have also shown that taurolidine lock solution leads to decreased CRBSI episodes. Several systematic reviews and meta-analysis consisted of taurolidine in adult, and pediatric populations also showed reduction in the incidence of CRBSIs. THERAPEUTIC ADVANCE: Taurolidine and heparin lock solution represents a novel preventive strategy for those undergoing hemodialysis through a CVC by reducing the risk of CRBSI. This is significant progress because there are no other similar options available for patients for whom catheters are the only options for their life-saving treatment.

Postpartum Fusobacterium gonidiaformans bacteremia.

We present a case of a healthy 29 year-old female with an uneventful vaginal delivery who had transient, sudden onset of rigors and fever 36 hours postpartum. She was found to have Fusobacterium gonidiaformans bacteremia due to retained placental tissue. We report this organism as it is not well-described and rarely reported. It does bear some similarities to other Fusobacterium species that have been reported to cause septicemia in young otherwise healthy patients.

Impact of Infectious Disease Consultation on Clinical Management and Mortality in Patients With Candidemia.

Candidemia has a high attributable mortality. The objective of this study was to determine the impact of infectious disease consultation on mortality and clinical outcomes in candidemia. Infectious disease consultation was associated with better adherence to guidelines and improved survival, even in patients with high Acute Physiology and Chronic Health Evaluation II scores.

Infection with New York Orthohantavirus and Associated Respiratory Failure and Multiple Cerebral Complications.

We report a case of infection with New York orthohantavirus in a woman who showed renal impairment and hemorrhage, complicated by hydrocephalus, in Long Island, New York, USA. Phylogenetic analysis showed that this virus was genetically similar to a New York orthohantavirus isolated in the same region during 1993.

Trauma patients meeting both Centers for Disease Control and Prevention's definitions for ventilator-associated pneumonia had worse outcomes than those meeting only one.

BACKGROUND: The Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) replaced its old definition for ventilator-associated pneumonia (VAP) with the ventilator-associated events algorithm in 2013. We sought to compare the outcome of trauma patients meeting the definitions for VAP in the two modules. METHODS: Trauma patients with blunt or penetrating injuries and with at least 2 d of ventilator support were identified from the trauma registry from 2013 to 2014. VAP was determined using two methods: (1) VAP as defined by the "old," clinically based NHSN definition and (2) possible VAP as defined by the updated "new" NHSN definition. Cohen's kappa statistic was determined to compare the two definitions for VAP. To compare demographic and clinical outcomes, the chi-square and Student's t-tests were used for categorical and continuous variables, respectively. RESULTS: From 2013 to 2014, there were 1165 trauma patients admitted who had at least 2 d of ventilator support. Seventy-eight patients (6.6%) met the "new" NHSN definition for possible VAP, 361 patients (30.9%) met the "old" definition of VAP, and 68 patients (5.8%) met both definitions. The kappa statistic between VAP as defined by the "new" and "old" definitions was 0.22 (95% confidence interval, 0.17-0.27). There were no differences in age, gender, race, or injury severity score when comparing patients who met the different definitions. Those satisfying both definitions had longer ventilator support days (P = 0.0009), intensive care unit length of stay (LOS; P = 0.0003), and hospital LOS (P = 0.0344) when compared with those meeting only one definition. There was no difference in mortality for those meeting both and those meeting the old definition for VAP; patients meeting both definitions had higher respiratory rate at arrival (P = 0.0178). CONCLUSIONS: There was no difference in mortality between patients meeting the "old" and "new" NHSN definitions for VAP; those who met "both" definitions had longer ventilator support days, intensive care unit, and hospital LOS.

Prevention and Treatment of Cancer-Related Infections, Version 2.2016, NCCN Clinical Practice Guidelines in Oncology.

Infectious diseases are important causes of morbidity and mortality in patients with cancer. The NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prevention and Treatment of Cancer-Related Infections characterize the major pathogens to which patients with cancer are susceptible, with a focus on the prevention, diagnosis, and treatment of major common and opportunistic infections. This portion of the guidelines highlights the sections on antifungal and antiviral prophylaxis. Antifungal and antiviral prophylaxis recommendations have expanded over the past few years. New agents for the treatment of fungal infections and incorporation of therapeutic drug monitoring are presented. Antiviral prophylaxis for hepatitis B and management considerations for hepatitis C and HIV have been further developed.

Point-of-prescription interventions to improve antimicrobial stewardship.

Antimicrobial stewardship is pivotal to improving patient outcomes, reducing adverse events, decreasing healthcare costs, and preventing further emergence of antimicrobial resistance. In an era in which antimicrobial resistance is increasing, judicious antimicrobial use is the responsibility of every healthcare provider. Antimicrobial stewardship programs (ASPs) have made headway in improving antimicrobial prescribing using such "top-down" methods as formulary restriction and prospective audit with feedback; however, engagement of prescribers has not been fully explored. Strategies that include frontline prescribers and other unit-based healthcare providers have the potential to expand stewardship, both to augment existing centralized ASPs and to provide alternative approaches to perform stewardship at healthcare facilities with limited resources. This review discusses interventions focusing on antimicrobial prescribing at the point of prescription as well as a pilot project to engage unit-based healthcare providers in antimicrobial stewardship.

A unique case of hypervirulent Klebsiella pneumoniae acute cholecystitis complicated by portal vein thrombophlebitis: A case report and literature review.

Hypervirulent Klebsiella pneumoniae remains a significant global public health concern, characterized by a unique syndrome involving monomicrobial primary pyogenic liver abscesses, often leading to metastatic complications such as endophthalmitis, meningitis, and other infections. These infections are frequently observed in immunocompetent hosts or diabetic patients, particularly those of Asian ethnicity. In this report, we present the case of a 66-year-old Burmese female, currently residing in the United States, who presented with severe swelling, pain, discharge, and vision loss in her left eye, along with abdominal pain. Subsequent investigation revealed monomicrobial Klebsiella pneumoniae acute cholecystitis with an adjacent liver abscess, complicated by bacteremia, endogenous endophthalmitis, and portal vein thrombosis. Treatment with ceftriaxone proved successful in addressing her intra-abdominal infections, while anticoagulation therapy was initiated following multidisciplinary discussions among all involved subspecialties. Early diagnosis and the timely administration of appropriate treatment are crucial in reducing mortality and preventing further complications.

Effectiveness of a multimodal strategy to reduce external ventricular drain-associated infection: A quasi-experimental study.

BACKGROUND: Infection is a serious complication in neurosurgical patients who undergo external ventricular drain (EVD) insertion. METHODS: We conducted a quasi-experimental study in patients who underwent EVD insertion to evaluate the impact of a multi-modal strategy to reduce the incidence of external ventricular drain associated infections (EVDAIs). The study was divided into 2 periods; (1) the pre-intervention period when techniques for EVD insertion and maintenance were up to the discretion of the neurosurgeons and (2) the post-intervention after implementation of a multi-modal strategy (cefazolin antibiotic prophylaxis, preoperative chlorhexidine showers, application of postoperative chlorhexidine-impregnated dressing, limited manipulation of the EVD, and meticulous EVD management). The primary outcome was the incidence rate of EVDAIs; secondary outcomes included in-hospital mortality rate, the hospital length of stay. RESULTS: In total, 135 patients were included. The incidence rate of EVDAIs was significantly reduced in the post-intervention period (5.6 cases/1,000 EVD-days) compared with the pre-intervention period (18.2 cases/1,000 EVD-days; P=0.026). There were no differences in all secondary outcomes analyzed. This multi-modal strategy was associated with high satisfaction among health care personnel. CONCLUSIONS: Implementation of a multi-modal strategy was associated with a reduction in the incidence of EVDAIs. This was in line with our goal of promoting a new culture of safety despite being in a resource-limited setting.

Mupirocin and chlorhexidine resistance in Staphylococcus aureus in patients with community-onset skin and soft tissue infections.

Decolonization measures, including mupirocin and chlorhexidine, are often prescribed to prevent Staphylococcus aureus skin and soft tissue infections (SSTI). The objective of this study was to determine the prevalence of high-level mupirocin and chlorhexidine resistance in S. aureus strains recovered from patients with SSTI before and after mupirocin and chlorhexidine administration and to determine whether carriage of a mupirocin- or chlorhexidine-resistant strain at baseline precluded S. aureus eradication. We recruited 1,089 patients with community-onset SSTI with or without S. aureus colonization. In addition to routine care, 483 patients were enrolled in a decolonization trial: 408 received intranasal mupirocin (with or without antimicrobial baths), and 258 performed chlorhexidine body washes. Patients were followed for up to 12 months with repeat colonization cultures. All S. aureus isolates were tested for high-level mupirocin and chlorhexidine resistance. At baseline, 23/1,089 (2.1%) patients carried a mupirocin-resistant S. aureus strain and 10/1,089 (0.9%) patients carried chlorhexidine-resistant S. aureus. Of 4 patients prescribed mupirocin, who carried a mupirocin-resistant S. aureus strain at baseline, 100% remained colonized at 1 month compared to 44% of the 324 patients without mupirocin resistance at baseline (P = 0.041). Of 2 patients prescribed chlorhexidine, who carried a chlorhexidine-resistant S. aureus strain at baseline, 50% remained colonized at 1 month compared to 48% of the 209 patients without chlorhexidine resistance at baseline (P = 1.0). The overall prevalence of mupirocin and chlorhexidine resistance is low in S. aureus isolates recovered from outpatients, but eradication efforts were less successful in patients carrying a mupirocin-resistant S. aureus strain at baseline.

Prevention and treatment of hemodialysis-related bloodstream infections.

Despite improvements in the delivery of care, the annual all-cause mortality rate for end-stage renal disease (ESRD) patients is still around 220 deaths per 1000 at risk patient-years. Infection-related causes are second only to cardiovascular events as a cause for mortality among ESRD patients. Almost two-thirds of all ESRD patients will require hemodialysis and they are at the highest risk for bloodstream infections. An effective method for reducing bloodstream infections is increasing the use of fistula for dialysis access, but, for a significant number of patients, catheter access is inevitable. Several interventions have been studied that primarily involves the application of antimicrobials at the catheter exit site. Other interventions include the use of antibiotic lock solutions, which have resulted in the development of antibiotic resistance. Novel connecting devices may be of use in the future, but studies are still needed to show their efficacy at preventing catheter-related bloodstream infections among hemodialysis patients. As insertion sites can be limited in hemodialysis patients, treatment of certain catheter-related bloodstream infections can be amenable to catheter retention as long as both systemic antibiotic and antibiotic lock therapies are also initiated. Until more data are available, catheter removal followed by systemic therapy is preferred for infections involving Staphylococcus aureus, Pseudomonas species, Enterococcus species, and Candida species.

Mpox Update: Clinical Presentation, Vaccination Guidance, and Management.

Following the eradication of smallpox, intermittent small outbreaks of mpox (monkeypox) have occurred with increasing frequency, primarily in endemic regions of Africa. With the rapid spread of mpox around the globe in 2022, we are approaching a second zoonotic pandemic of the 21st century. Given the predominance of cutaneous involvement in mpox, dermatologists should be prepared to recognize the clinical features and manage this increasingly prevalent disease. This article reviews a brief history of the mpox virus, clinical presentation, complications, approach to diagnosis, methods of transmission, infection control recommendations, indications for vaccination, and therapeutic options to inform dermatologists on the frontline of the mpox epidemic.

Impact of Pharmacist-Led Multidisciplinary Team to Attain Targeted Vancomycin Area under the Curved Monitoring in a Tertiary Care Center in Thailand.

Vancomycin Area Under the Curve (AUC) monitoring has been recommended to ensure successful clinical outcomes and minimize the risk of nephrotoxicity, rather than traditional trough concentration. However, vancomycin AUC monitoring by a pharmacist-led multidisciplinary team (PMT) has not been well established in Southeast Asia. This study was conducted at Thammasat University Hospital. Adult patients aged ≥ 18 years who were admitted and received intravenous vancomycin ≥48 h were included. The pre-PMT period (April 2020-September 2020) was defined as a period using traditional trough concentration, while the post-PMT period (October 2020-March 2021) was defined as a period using PMT to monitor vancomycin AUC. The primary outcome was the rate of achievement of the therapeutic target of an AUC/MIC ratio of 400-600. There was a significantly higher rate of achievement of therapeutic target vancomycin AUC during post-PMT period (66.7% vs. 34.3%, p < 0.001). Furthermore, there was a significant improvement in the clinical cure rate (92.4% vs. 69.5%, p < 0.001) and reduction in 30-day ID mortality (2.9% vs. 12.4%, p = 0.017) during the post-PMT period. Our study demonstrates that PMT was effective to help attain a targeted vancomycin AUC, improve the clinical cure rate, and reduce 30-day ID mortality. This intervention should be encouraged to be implemented in Southeast Asia.

Antibiotic prescribing behavior among physicians in Asia: a multinational survey.

Objective: To evaluate antibiotic prescribing behavior (APB) among physicians with various specialties in five Asian countries. Design: Survey of antibiotics prescribing behavior in three stages (initial, on-treatment, and de-escalation stages). Methods: Participants included internists, infectious diseases (ID) specialists, hematologists, intensivists, and surgeons. Participants' characteristics, patterns of APB, and perceptions of antimicrobial stewardship were collected. A multivariate analysis was conducted to evaluate factors associated with appropriate APB. Results: There were 367 participants. The survey response rate was 82.5% (367/445). For the initial stage, different specialties had different choices for empiric treatment. For the on-treatment stage, if the patient does not respond to empiric treatment, most respondents will step up to broader-spectrum antibiotics (273/367: 74.39%). For the de-escalation stage, the rate of de-escalation was 10%-60% depending on the specialty. Most respondents would de-escalate antibiotics based on guidelines (250/367: 68.12%). De-escalation was mostly reported by ID specialists (66/106: 62.26%). Respondents who reported that they performed laboratory investigations prior to empirical antibiotic prescriptions (aOR = 2.83) were associated with appropriate use, while respondents who reported ID consultation were associated with appropriate antibiotic management for infections not responding to empiric treatment (aOR = 40.87); adherence with national guidelines (aOR = 2.57) was associated with reported successful carbapenem de-escalation. Conclusion: This study highlights the variation in practices and gaps in appropriate APB on three stages of antibiotic prescription among different specialties. Education on appropriate investigation, partnership with ID specialist, and availability and adherence with national guidelines are critical to help guide appropriate APB among different specialties.

Acute renal insufficiency during telavancin therapy in clinical practice.

OBJECTIVES: To describe the tolerance to long-term telavancin therapy among inpatients as it relates to nephrotoxicity. METHODS: Retrospective cohort study of adult patients who received telavancin at the Barnes-Jewish Hospital from 1 September 2009 to 1 December 2010. Patients who received less than three doses of telavancin, were on haemodialysis prior to telavancin administration or died within 48 h of initial telavancin administration were excluded. RESULTS: Twenty-one patients received telavancin and met the inclusion criteria. Seven of 21 patients (33%) developed acute renal insufficiency during therapy. Patients who developed acute renal insufficiency had a mean glomerular filtration rate reduction of 56 mL/min/1.73 m(2). In the univariate analysis, high body mass index (P=0.025), use of intravenous contrast dye (P=0.017) and prior serum vancomycin trough levels >20 mg/L (P=0.017) were associated with developing acute renal insufficiency. Two patients required haemodialysis; two had persistent renal insufficiency. CONCLUSIONS: Supratherapeutic vancomycin trough levels, high body mass index and receipt of intravenous contrast dye prior to telavancin therapy were associated with acute renal insufficiency.

The role of the clinical pharmacist in antimicrobial stewardship in Asia: A review.

Clinical pharmacist-driven antimicrobial stewardship programs (ASPs) have been successfully implemented. Although relevant guidance and several studies suggest that clinical pharmacists be integrated into the current ASP team model, barriers still exist in Asia, primarily due to lack of dedicated personnel and lack of career advancement. We review the effectiveness and the ideal role of clinical pharmacist among ASPs in Asia. Several studies conducted in Asia have shown the effectiveness of pharmacist-led ASP interventions in hospitals and other healthcare settings. However, opportunities to expand the role of clinical pharmacists in ASPs in Asia exist in the implementation of rapid diagnostic test and drug allergies.

Perioperative Interventions to Reduce Surgical Site Infections: A Review.

Surgical site infections (SSIs) contribute to increased health care costs and morbidity after procedures as well as prolonged length of stay. Perioperative personnel can use a variety of interventions to help reduce SSI incidence; however, all strategies are not effective for all patients (eg, antibiotic prophylaxis). Results of randomized controlled trials show that some SSI reduction strategies are generally effective, including preoperative skin antisepsis with an alcohol-based agent, closing surgical wounds with triclosan-coated suture, and applying a negative pressure wound therapy device to open and closed wounds. Study results do not show that irrigating clean wounds with crystalloid solutions containing antibiotics or routinely using plastic drapes with or without impregnated iodophor or silver nylon-impregnated dressings significantly reduces SSI incidence. Perioperative leaders should support the implementation of strategies to prevent SSIs and work with interdisciplinary team members to develop an SSI prevention bundle that will meet the needs of their patients.

Utilizing technology to enhance screening for highly infectious diseases.

Quick identification and isolation of patients with highly infectious diseases is extremely important in healthcare settings today. This study focused on the creation of a digital screening tool using a free and publicly available digital survey application to screen patients during a measles outbreak in New York City. The results indicate that digital tools are an effective alternative to paper tools due to their ease of use and remote compliance monitoring capabilities.