Rapid Molecular Testing for UTIs: A Diagnostic Stewardship Perspective.

With increased focus on antimicrobial stewardship in post-acute, long-term care (PALTC) settings, optimization of diagnostic testing is essential. Molecular diagnostics are currently being offered and used for the diagnosis of urinary tract infections (UTIs) in community and PALTC settings. Yet, no studies to date explore the role of rapid diagnostics such as polymerase chain reaction and other molecular methods in the stewardship efforts of PALTC settings, specifically compared with standard testing with urinalysis and culture with antimicrobial susceptibility testing. This article outlines a framework of diagnostic stewardship to critically evaluate the use of molecular diagnostics for the diagnosis of UTIs in PALTC and the impact on patient outcomes and antimicrobial stewardship. The authors suggest a 5-step process for evaluating the role of novel diagnostics in the PALTC setting. Understanding the shortcomings of newer diagnostic tests may identify needs for further investigation before their widespread use.

Antimicrobial susceptibility testing: An updated primer for clinicians in the era of antimicrobial resistance: Insights from the Society of Infectious Diseases Pharmacists.

Antimicrobial susceptibility testing (AST) is a critical function of the clinical microbiology laboratory and is essential for optimizing care of patients with infectious diseases, monitoring antimicrobial resistance (AMR) trends, and informing public health initiatives. Several methods are available for performing AST including broth microdilution, agar dilution, and disk diffusion. Technological advances such as the development of commercial automated susceptibility testing platforms and the advent of rapid diagnostic tests have improved the rapidity, robustness, and clinical application of AST. Numerous accrediting and regulatory agencies are involved in the process of AST and setting and revising breakpoints, including the U.S. Food and Drug Administration and the Clinical and Laboratory Standards Institute. Challenges to optimizing AST include the emergence of new resistance mechanisms, the development of new antimicrobial agents, and generation of new data requiring updates and revisions to established methods and breakpoints. Together, the challenges in AST methods and their interpretation create important opportunities for well-informed clinicians to improve patient outcomes and provide value to antimicrobial stewardship programs, especially in the setting of rapidly changing and increasing AMR. Addressing AST challenges will involve continued development of new technologies along with collaboration between clinicians and the laboratory to facilitate optimal antimicrobial use, combat the increasing burden of AMR, and inform the development of novel antimicrobials. This updated primer serves to reinforce important principles of AST, and to provide guidance on their implementation and optimization.

The Power of Peer Mentoring to Support Women Pharmacy Faculty Personally and Professionally.

Regardless of a faculty member's career stage, effective mentoring is critical for successful professional development and a thriving academic career. Traditional mentor-mentee relationships can be effective but may present challenges for some faculty depending on their individual needs and institutional resources. The use of peer mentoring circles, where group members serve as both mentor and mentee, may provide additional resources and benefits to faculty at all career stages and appear especially beneficial for women faculty because of their focus on interconnectedness and collaboration. However, literature is scarce regarding effective mentoring strategies for women pharmacy faculty. As members of one women faculty-only peer mentoring circle, we describe our experiences using this mentoring strategy and offer recommendations for other faculty members considering this approach.

Optimizing rapid diagnostics and diagnostic stewardship in Gram-negative bacteremia.

Antimicrobial resistance remains a high global concern, as it is associated with prolonged hospitalizations, increased morbidity and mortality, and escalating healthcare-related costs. Rapid diagnostic technology (RDT) has become the cornerstone in achieving prompt blood culture results providing a quicker initiation of optimal therapy, decreased mortality, and decreased spread of resistance. To maximize the benefits of RDTs, antimicrobial stewardship programs must implement a diagnostic stewardship (DS) subgroup to optimize communication, education, and interpretation of RDT results within the healthcare system. The DS subgroup is necessary to evaluate the technologies available, better integrate the selected technologies into the healthcare system, and develop innovative and appropriate use to improve patient outcomes.

Strategies for Students to Optimize Their Learning Experience in Virtual Patient-Care Settings.

Authors respond to the article by Dr. Karaoui and colleagues from the November issue of volume 35 in this journal that describes challenges in pharmacy education due to the COVID-19 pandemic. The authors are students who provide strategies for student success while on virtual introductory or Advanced Pharmacy Practice Experiences during COVID-19.

Evaluation of team communication in an interprofessional inpatient transition of care simulation.

Background: Interprofessional education (IPE) provides unique opportunities for students to better understand their roles, roles of other healthcare professionals, and prepare for teamwork for patient benefit. Interprofessional team education is recognized as a key element in the 2016 ACPE standards. Objective: Assess student self-perceived competence in four IPEC domains after an inpatient simulation activity. Methods: Pre/post-test design used the Interprofessional Education Collaborative Competency Survey. The activity included medical, nursing, social work, and pharmacy students working in healthcare teams to develop collaborative treatment plans for simulated patients with altered mental status. Results: Ninety-seven health profession students completed the activity, while 49 second-year (P2) student pharmacists participated in the study. All completed a pre-test and 47/49 (96%) completed a post-test. At pre-test, students ranked themselves highest in abilities to respect patient privacy (100% strongly agree) and acting with honesty and integrity in relationships (100% strongly agree). They reported lower ability in describing team development process. At post-test, significant increases were seen in managing ethical dilemmas (p < .002) and respect (p = .49), though decreases were seen in using appropriate or respectful language (p < .02). Conclusion: Significant differences in student perceptions of ethics and communication were observed after participation in a transition of care inpatient IPE simulation.

It's time to rethink your approach to C diff infection.

Metronidazole is no longer the drug of choice for first-line therapy. And fecal microbiota transplantation has proven effective for certain patients.

Assessment of mortality stratified by meropenem minimum inhibitory concentration in patients with Enterobacteriaceae bacteraemia: A patient-level analysis of published data.

In 2010, the Clinical and Laboratory Standards Institute (CLSI) lowered carbapenem breakpoints to reduce the proportion of 'susceptible' organisms that produced carbapenemases. Few studies have evaluated the effect of this change on clinical outcomes. This systematic review aimed to evaluate the effect of carbapenem MICs on 30-day mortality from pooled patient-level data from studies of patients treated with carbapenems across a range of meropenem MICs. PubMed was searched to March 2019 with the terms 'carbapenem', 'meropenem', 'imipenem', 'doripenem', 'ertapenem', 'susceptibility' and 'outcomes'. Studies were included in the analysis if patients had Enterobacteriaceae bacteraemia treated with a carbapenem for ≥48 h and mortality was reported. Studies were excluded if all isolates were either susceptible or resistant to meropenem based on CLSI 2010 breakpoints or if only carbapenemase-producing isolates were included. Authors were contacted for patient-level data. The primary outcome was 30-day mortality, with planned subset analyses of patients treated with meropenem, receiving active combination therapy, treated in the ICU or infected with Klebsiella pneumoniae. Of 157 articles identified, 4 met the inclusion criteria (115 eligible patients). The odds of mortality increased with each increasing meropenem MIC dilution (OR = 1.51, 95% CI 1.06-2.15) as a continuous variable. A similar increase in odds was observed in patients treated with meropenem, treated in the ICU, infected with K. pneumoniae or receiving no other active antimicrobials. Increasing meropenem MICs in Enterobacteriaceae were associated with increased mortality; however, more work is needed to define optimal clinical decision rules for infections within the susceptible range.

A Comprehensive Survey of Infectious Diseases Curriculum Among US Pharmacy Schools.

Objective. To describe what and how infectious diseases (ID) topics are taught in US schools of pharmacy and summarize pharmacy faculty members' and students' perceived successes and challenges in teaching and learning about ID. Methods. A 23-item survey instrument was distributed electronically to ID faculty members at 137 US pharmacy schools. Data collected included curricular hours and format, topics covered, active-learning strategies, and curricular successes and concerns. Results. Surveys were collected from 106 schools (77% response rate). Infectious diseases curricula were allotted a median of 60 (IQR=40) hours of classroom time. Respondents dedicated 33% of curriculum hours to ID fundamentals and 66% to disease states. Greater than 94% of schools taught all tier one ID topics from the 2016 American College of Clinical Pharmacy Pharmacotherapy Didactic Curriculum Toolkit. Curricula were primarily delivered through traditional lectures rather than active learning (75% vs 25% of classroom time, respectively). The median number of active-learning strategies used was four (IQR=3). The most common active-learning modalities used either consistently or frequently were patient case application (98%) and audience response systems (76%). The most common successes cited by faculty members were implementation of active learning, the "real-world" applicability of the ID topics, and the breadth of topics and topic exposure covered in the curriculum. The most common concerns were a lack of time to cover material and the amount of material covered. Conclusion. Increased communication and collaboration between ID educators is warranted to increase consistency of ID education and distribution of educational innovations.

Evaluation of pharmacy student perceptions and stereotypes of healthcare professionals before and after an internal medicine advanced pharmacy practice experience.

BACKGROUND: A focus of delivering effective patient-centered care is working as an interprofessional team. Pharmacy students may harbor stereotypes of other healthcare professions that could impede collaboration. The objective of this study was to assess pharmacy student ratings of pharmacists and other healthcare professionals' characteristics before and after their internal medicine advanced pharmacy practice experience (APPE) to determine if the APPE altered their stereotypes. A pre- and post-survey utilizing the Student Stereotypes Rating Questionnaire (SSRQ) was used to carry out the study goals. IMPACT: Students had more interactions with pharmacists, physicians, and nurses than with other professionals. Pharmacy students' perceptions of their own profession (autostereotypes) were higher compared to the other disciplines, with a movement towards equality following APPE completion. Students also rated professionals lower if they completed the survey in earlier APPE blocks. These results are limited by the lack of coupling between surveys, a low response rate, and incomplete surveys. RECOMMENDATIONS: Methods that would have strengthened results include focusing on the healthcare professionals that students interacted with most, quantifying the number of experiences they had with each group before and after the rotation, requiring answers to all survey questions, and a strategy to match pre- and post-survey results. DISCUSSION: Despite the limitations of the study, the experiences gained during the APPE positively impacted student perceptions and attitudes towards other healthcare disciplines. This experience type may be a key component to producing pharmacy graduates who are prepared to work collaboratively with other professionals.

Clostridium tertium bacteremia and hepatic abscess in a non-neutropenic patient.

A 43-year-old previously healthy man presented with altered mental status, diaphoresis, and fevers following a ruptured appendicitis and appendectomy. The patient had growth of Clostridium tertium and Escherichia coli in blood cultures and imaging of the abdomen revealed a large hepatic abscess. Clostridium tertium is an uncommon cause of bacteremia in non-neutropenic patients. There is currently no universally accepted treatment for Clostridium tertium bacteremia. We report successful treatment with ertapenem.

Comprehensive Assessment of Didactic Curriculum and Career Interest in Infectious Diseases Among Graduating United States Pharmacy Students.

BACKGROUND: The growing need for clinicians with antimicrobial stewardship (AS) skills has resulted in an examination of educational methods for pharmacy and medical learners. This study explores characteristics associated with student assessment of didactic infectious diseases (ID) education quality and variables associated with a career interest in ID and/or AS. METHODS: Infectious diseases faculty from US pharmacy schools were sent a 15-question survey in September 2017. Faculty members e-mailed the survey link to graduating pharmacy students. RESULTS: Participants from 29 pharmacy schools, representing 21 states, resulted in 537 student responses. Quality of ID didactic education was rated as Very Good by 41%, Good by 40%, Acceptable by 14%, and Poor by 4% of participants. The mean number of faculty-provided learning resources differed by quality rating and was significantly associated with perceived educational needs. Infectious diseases was identified as a career interest by 29% of students. These students more frequently rated their ID didactic education as Very Good (52% vs 37%, P < .01) and were more likely to become interested in ID during or after it was taught in pharmacy school (39% vs 21%, P < .01). CONCLUSIONS: In this cohort of graduating pharmacy students, the perceived quality of didactic ID education was associated with a career interest in ID and/or AS. Factors associated with quality of education were quantity and quality of faculty-provided resources. Increasing the quality of the didactic ID curriculum has potential to increase interest in ID/AS careers among pharmacy students.

Outcomes and Risk Factors for Mortality among Patients Treated with Carbapenems for Klebsiella spp. Bacteremia.

BACKGROUND: Extensive dissemination of carbapenemase-producing Enterobacteriaceae has led to increased resistance among Klebsiella species. Carbapenems are used as a last resort against resistant pathogens, but carbapenemase production can lead to therapy failure. Identification of risk factors for mortality and assessment of current susceptibility breakpoints are valuable for improving patient outcomes. AIM: The objective of this study was to evaluate outcomes and risk factors for mortality among patients treated with carbapenems for Klebsiella spp. bacteremia. METHODS: Patients hospitalized between 2006 and 2012 with blood cultures positive for Klebsiella spp. who received ≥ 48 hours of carbapenem treatment within 72 hours of positive culture were included in this retrospective study. Patient data were retrieved from electronic medical records. Multivariate logistic regression was used to identify risk factors for 30-day hospital mortality. RESULTS: One hundred seven patients were included. The mean patient age was 61.5 years and the median APACHE II score was 13 ± 6.2. Overall, 30-day hospital mortality was 9.3%. After adjusting for confounding variables, 30-day mortality was associated with baseline APACHE II score (OR, 1.17; 95% CI, 1.01-1.35; P = 0.03), length of stay prior to index culture (OR, 1.03; 95% CI, 1.00-1.06; P = 0.04), and carbapenem non-susceptible (imipenem or meropenem MIC > 1 mg/L) infection (OR, 9.08; 95% CI, 1.17-70.51; P = 0.04). CONCLUSIONS: Baseline severity of illness and length of stay prior to culture were associated with 30-day mortality and should be considered when treating patients with Klebsiella bacteremia. These data support the change in carbapenem breakpoints for Klebsiella species.

Significant publications on infectious diseases pharmacotherapy in 2011.

PURPOSE: Important articles on topics pertinent to infectious diseases (ID) pharmacotherapy published in prominent peer-reviewed journals in 2011 are summarized. SUMMARY: Pharmacists, physicians, and researchers from the Houston Infectious Diseases Network were asked to nominate articles published in 2011 that they perceived as having a significant impact on the field of ID pharmacotherapy. The resulting list, comprising 10 articles related to human immunodeficiency virus (HIV) disease or acquired immune deficiency syndrome (AIDS) and 38 articles on a broad range of other ID-related topics, was sent to members of the Society of Infectious Diseases Pharmacists (SIDP) for evaluation via an Internet survey. The survey participants were asked to select 10 articles from the list of general ID articles and 1 article from the HIV- or AIDS-related articles that they viewed as having the most impact on the field. Of the 328 SIDP members surveyed, 120 (37%) ranked the non-HIV-related papers and 55 (17%) ranked the HIV-related papers. The 12 highest-ranked items-including 3 guidelines-are summarized here. CONCLUSION: Due to the increasing number of articles published each year, it is difficult to maintain a current knowledge of significant publications in the field of ID pharmacotherapy. This review of the key articles in 2011 may be helpful to the nonspecialist clinician by lessening this burden.