Can a collaborative subspecialty antimicrobial stewardship intervention have lasting effects?

OBJECTIVE: We previously demonstrated the benefit of direct, daily collaboration between infectious disease (ID) and critical care practitioners (CCP) on guideline adherence and antibiotic use in the medical intensive care unit (MICU). In this post-intervention review, we sought to establish whether the effect on antibiotic use and guideline adherence was sustainable. DESIGN: A retrospective review of 87 patients, admitted to the 24-bed MICU, was done 3 (n = 45) and 6 months (n = 42) after the intervention. MEASUREMENTS: Data included demographics, severity indicators, admitting pathology, infectious diagnosis, clinical outcomes [mechanical ventilation days (MVD) and MICU length of stay (LOS), antibiotic days of therapy (DOT), in-hospital mortality], and antibiotic appropriateness based on current guidelines. RESULTS: In the 3-month (3-PI) and 6-month post-intervention (6-PI), there were no significant differences in the APACHE II score, MVD, LOS, DOT, or total antibiotic use at 3 (p = 0.59) and 6-PI (p = 0.87). There was no change in the mean use of extended-spectrum penicillins, cephalosporin, and carbapenems. While there were significant differences in vancomycin usage at 3-PI [3.1 DOT vs. 4.3 DOT (p = 0.007)], this finding was not seen after 6 months [3.1 DOT vs. 3.4 DOT (p = 0.08)]. When compared to the intervention period, the inappropriateness of antibiotic use at 3 (p = 1.00) and 6-PI (p = 0.30) did not change significantly. CONCLUSIONS: There were no significant differences in either total antibiotic use or inappropriate antibiotic use at the 6-PI time period. Continuous, daily, direct collaboration between ID and CCP, once implemented, can have lasting effects even at 6 months after the interaction has been discontinued.

Filtering authentic sepsis arising in the ICU using administrative codes coupled to a SIRS screening protocol.

PURPOSE: Using administrative codes and minimal physiologic and laboratory data, we sought a high-specificity identification strategy for patients whose sepsis initially appeared during their ICU stay. MATERIALS AND METHODS: We studied all patients discharged from an academic hospital between September 1, 2013 and October 31, 2014. Administrative codes and minimal physiologic and laboratory criteria were used to identify patients at high risk of developing the onset of sepsis in the ICU. Two clinicians then independently reviewed the patient record to verify that the screened-in patients appeared to become septic during their ICU admission. RESULTS: Clinical chart review verified sepsis in 437/466 ICU stays (93.8%). Of these 437 encounters, only 151 (34.6%) were admitted to the ICU with neither SIRS nor evidence of infection and therefore appeared to become septic during their ICU stay. CONCLUSIONS: Selected administrative codes coupled to SIRS criteria and applied to patients admitted to ICU can yield up to 94% authentic sepsis patients. However, only 1/3 of patients thus identified appeared to become septic during their ICU stay. Studies that depend on high-intensity monitoring for description of the time course of sepsis require clinician review and verification that sepsis initially appeared during the monitoring period.

Disseminated Herpes Simplex Virus with Fulminant Hepatitis.

Disseminated herpes simplex virus (HSV) is a rare cause of acute fulminant liver failure. We hereby present a case series of three patients with acute disseminated HSV with necrotizing hepatitis successfully treated with a week course of acyclovir. Early empiric administration of acyclovir therapy while awaiting confirmatory tests is critical in this potentially lethal disease.

Risk of redocumenting penicillin allergy in a cohort of patients with negative penicillin skin tests.

BACKGROUND: Even though electronic documentation of allergies is critical to patient safety, inaccuracies in documentation can potentiate serious problems. Prior studies have not evaluated factors associated with redocumenting penicillin allergy in the medical record despite a proven tolerance with a penicillin skin test (PST). OBJECTIVE: Assess the prevalence of reinstating inaccurate allergy information and associated factors thereof. DESIGN: We conducted a retrospective observational study from August 1, 2012 to July 31, 2013 of patients who previously had a negative PST. We reviewed records from the hospital, long-term care facilities (LTCF), and primary doctors' offices. SETTING: Vidant Health, a system of 10 hospitals in North Carolina. SUBJECTS: Patients with proven penicillin tolerance rehospitalized within a year period from the PST. MEASUREMENTS: We gauged hospital reappearances, penicillin allergy redocumentation, residence, antimicrobial use, and presence of dementia or altered mentation. RESULTS: Of the 150 patients with negative PST, 55 (37%) revisited a Vidant system hospital within a 1-year period, of whom 21 were LTCF residents. Twenty (36%) of the 55 patients had penicillin allergy redocumented without apparent reason. Factors associated with penicillin allergy redocumentation included age >65 years (P = 0.011), LTCF residence (P = 0.0001), acutely altered mentation (P < 0.0001), and dementia (P < 0.0001). Penicillin allergy was still listed in all 21 (100%) of the LTCF records. CONCLUSIONS: At our hospital system, penicillin allergies are often redocumented into the medical record despite proven tolerance. The benefits of PST may be limited by inadequately removing the allergy from different electronic/paper hospital, LTCF, primary physician, and community pharmacy records.

Impact of regular collaboration between infectious diseases and critical care practitioners on antimicrobial utilization and patient outcome.

OBJECTIVE: Antimicrobial stewardship programs have been shown to help reduce the use of unnecessary antimicrobial agents in the hospital setting. To date, there has been very little data focusing on high-use areas, such as the medical ICU. A prospective intervention was done to assess guideline compliance, antimicrobial expenditure, and healthcare cost when an infectious disease fellow interacts regularly with the medical ICU team. DESIGN: A 3-month retrospective chart review was followed by a 3-month prospective intervention the following year. Two hundred forty-six total charts were reviewed to assess generally accepted guideline compliance, demographics, and microbiologic results. SETTING: Twenty-four-bed medical ICU at an 861-bed tertiary care, university teaching hospital in North Carolina. SUBJECTS: Patients receiving antibiotics in the medical ICU. INTERVENTION: During the intervention period, the infectious disease fellow reviewed the charts, including physician notes and microbiology data, and discussed antimicrobial use with the medical ICU team. MEASUREMENTS AND MAIN RESULTS: Antimicrobial use, treatment duration, Acute Physiology and Chronic Health Evaluation II scores, length of stay, mechanical ventilation days, and mortality rates were compared during the two periods. RESULTS: No baseline statistically significant differences in the two groups were noted (i.e., age, gender, race, or Acute Physiology and Chronic Healthcare Evaluation II scores). Indications for antibiotics included healthcare-associated (53%) and community-acquired pneumonias (17%). Significant reductions were seen in extended-spectrum penicillins (p=0.0080), carbapenems (p=0.0013), vancomycin (p=0.0040), and metronidazole (p=0.0004) following the intervention. Antimicrobial modification led to an increase in narrow-spectrum penicillins (p=0.0322). The intervention group had a significantly lower rate of treatments that did not correspond to guidelines (p<0.0001). There was a reduction in mechanical ventilation days (p=0.0053), length of stay (p=0.0188), and hospital mortality (p=0.0367). The annual calculated healthcare savings was $89,944 in early antibiotic cessation alone. CONCLUSION: Active communication with an infectious disease practitioner can significantly reduce medical ICU antibiotic overuse by earlier modification or cessation of antibiotics without increasing mortality. This in turn can reduce healthcare costs, foster prodigious education, and strengthen relations between the subspecialties.

The impact of penicillin skin testing on clinical practice and antimicrobial stewardship.

BACKGROUND: Penicillin skin testing (PST) is a simple and reliable way of diagnosing penicillin allergy. After being off the market for 4 years, penicilloyl-polylysine was reintroduced in 2009 as PRE-PEN. We describe the negative predictive value (NPV) of PST and the impact on antibiotic selection in a sample of hospitalized patients with a reported history of penicillin allergy. METHODS: We introduced a quality improvement process at our 861-bed tertiary care hospital that used PST to guide antibiotic usage in patients with a history consistent with an immunoglobulin E (IgE)-mediated reaction to penicillin. Subjects with a negative PST were then transitioned to a ß-lactam agent for the remainder of their therapy. NPV of skin testing was established at 24-hour follow-up. We are reporting the result of 146 patients tested between March 2012 and July 2012. RESULTS: A total of 146 patients with a history of penicillin allergy and negative PST were treated with ß-lactam antibiotics. Of these, only 1 subject experienced an allergic reaction to the PST. The remaining 145 patients tolerated a full course of ß-lactam therapy without an allergic response, giving the PST a 100% NPV. We estimated that PST-guided antibiotic alteration for these patients resulted in an estimated annual savings of $82,000. CONCLUSION: Patients with a history of penicillin allergy who have a negative PST result are at a low risk of developing an immediate-type hypersensitivity reaction to ß-lactam antibiotics. The increased use of PST may help improve antibiotic stewardship in the hospital setting.

Medical care of pregnant women in eastern North Carolina with human immunodeficiency virus.

OBJECTIVES: To assess the time lag between the diagnosis of human immunodeficiency virus (HIV) and the initiation of antiretroviral therapy (ART) in pregnant women. METHODS: A retrospective chart review of 105 deliveries from HIV-positive women from January 2001 to June 2009 was undertaken. RESULTS: One hundred five HIV-infected pregnant women were identified and studied. Forty-eight women were diagnosed during the prenatal visit: 21 in the first trimester, 17 in the second trimester, and 10 in the third trimester. Forty-five had undetectable viral loads at delivery. The time lag between diagnosis of HIV and initiation of ART was 1 month for 31% and 3 months for 28.5%. CONCLUSIONS: The time lag between diagnosis of HIV and initiation of ART was more than 1 month in 69% of the expectant mothers, which may have contributed to the failure in viral suppression. Implementation of HIV screening and a more effective means of communication between prenatal and HIV clinics are required to help reduce vertical transmission of the virus to neonates.

Use of voriconazole for the treatment of Paecilomyces lilacinus cutaneous infections: case presentation and review of published literature.

The fungus Paecilomyces lilacinus is a rare but emerging pathogen that causes severe human infections, especially in immunocompromised hosts. It is an important organism to identify due to its poor susceptibility to conventional antifungal drugs, including amphotericin B, itraconazole, and fluconazole. Oculomycosis and cutaneous infections are the two most common manifestations of P. lilacinus infections. Voriconazole has been used successfully to treat P. lilacinus endophthalmitis, but reports of skin and soft tissue infections treated with voriconazole are limited to six prior publications. Our immunocompromised patient had a subcutaneous P. lilacinus infection successfully treated with 3 months of voriconazole therapy.

A case of Exophiala oligosperma successfully treated with voriconazole.

Exophiala oligosperma is an uncommon pathogen associated with human infections, predominantly in immunocompromised hosts. Case reports of clinical infections related to E. oligosperma have been limited to 6 prior publications, all of which have shown limited susceptibility to conventional antifungal therapies, including amphotericin B, itraconazole, and fluconazole. We describe the first case of an E. oligosperma induced soft-tissue infection successfully treated with a 3-month course of voriconazole without persisting lesions.