Implementation of an antimicrobial stewardship program for urinary tract infections in long-term care facilities: a cluster-controlled intervention study.

BACKGROUND: Widespread inappropriate use of antimicrobial substances drives resistance development worldwide. In long-term care facilities (LTCF), antibiotics are among the most frequently prescribed medications. More than one third of antimicrobial agents prescribed in LTCFs are for urinary tract infections (UTI). We aimed to increase the number of appropriate antimicrobial treatments for UTIs in LTCFs using a multi-faceted antimicrobial stewardship intervention. METHODS: We performed a non-randomized cluster-controlled intervention study. Four LTCFs of the Geriatric Health Centers Graz were the intervention group, four LTCFs served as control group. The main components of the intervention were: voluntary continuing medical education for primary care physicians, distribution of a written guideline, implementation of the project homepage to distribute guidelines and videos and onsite training for nursing staff. Local nursing staff recorded data on UTI episodes in an online case report platform. Two blinded reviewers assessed whether treatments were adequate. RESULTS: 326 UTI episodes were recorded, 161 in the intervention group and 165 in the control group. During the intervention period, risk ratio for inadequate indication for treatment was 0.41 (95% CI 0.19-0.90), p = 0.025. In theintervention group, the proportion of adequate antibiotic choices increased from 42.1% in the pre-intervention period, to 45.9% during the intervention and to 51% in the post-intervention period (absolute increase of 8.9%). In the control group, the proportion was 36.4%, 33.3% and 33.3%, respectively. The numerical difference between intervention group and control group in the post-intervention period was 17.7% (difference did not reach statistical significance). There were no significant differences between the control group and intervention group in the safety outcomes (proportion of clinical failure, number of hospital admissions due to UTI and adverse events due to antimicrobial treatment). CONCLUSIONS: An antimicrobial stewardship program consisting of practice guidelines, local and web-based education for nursing staff and general practitioners resulted in a significant increase in adequate treatments (in terms of decision to treat the UTI) during the intervention period. However, this difference was not maintained in the post-intervention phase. Continued efforts to improve the quality of prescriptions further are necessary. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov NCT04798365.

Vaccination acceptance and its associated factors in patients on hemodialysis in Austria: A nationwide survey.

BACKGROUND: Vaccines are essential in disease prevention among patients on chronic hemodialysis (HD). However, during the coronavirus disease 2019 pandemic, there has been an increased rate of vaccination hesitancy. A better understanding of patients' opinions may help identify a more targeted approach to increase vaccination rates. MATERIALS AND METHODS: Questionnaires with 43 questions based on the recommendations of the Strategic Advisory Group of Experts (SAGE) on Immunization Working Group on Vaccine Hesitancy were administered to patients during routine HD sessions at different dialysis centers in Austria. RESULTS: In total, 347 patients participated in this study. Approximately 81% of the patients were aged > 54 years, and 65% were men. Further, 53% of patients were receiving HD from private units. In ~ 72% of patients, the dialysis physicians were the source of vaccination information. Meanwhile, the source of information in 28% of patients was the primary care physician (28%), and 18% of patients obtained vaccination details from the internet. The number of younger (aged < 55 years) patients who were more likely to use online content as the main source of information was significantly higher than that of older patients (32 vs. 15%, p = 0.001). Furthermore, the number of older patients who wanted to receive more information from the dialysis physician was significantly higher than that of younger patients (57 vs. 38%, p = 0.009). Only 65% of patients had a good understanding of the mechanisms of action of vaccines. The younger population (aged 18 - 54 years) had a higher number of individuals with a good understanding of vaccine mechanisms than the older population (78 vs. 62%, p = 0.016). Moreover, 86% of the whole population wanted to complete the recommended vaccinations. However, only 39% of respondents had sufficient information about the vaccination plan in Austrian. CONCLUSION: Numerous patients receiving HD wanted to obtain more information from their dialysis physicians. Increased awareness among providers and targeted communication might increase vaccination rates.

Human Tularemia Epididymo-Orchitis Caused by Francisella tularensis Subspecies holartica, Austria.

A previously healthy man in Austria had tularemia epididymo-orchitis develop, leading to unilateral orchiectomy. Francisella tularensis subspecies holartica was detected by 16S rRNA gene sequencing analysis of inflamed granulomatous testicular tissue. Clinicians should suspect F. tularensis as a rare etiologic microorganism in epididymo-orchitis patients with relevant risk factors.

Sustained Increase in Very Low Influenza Vaccination Coverage in Residents and Healthcare Workers of Long-Term Care Facilities in Austria after Educational Interventions.

Residents of long-term care facilities (LTCFs) are particularly at risk for influenza infections. We aimed to improve influenza vaccination coverage among residents and healthcare workers (HCWs) in four LTCFs by implementing educational programs and enhanced vaccination services. We compared vaccination coverage before and after the interventions (2017/18 and 2018/19 seasons). Data on vaccination adherence were recorded during a four-year observational period (2019/20 to 2022/23 seasons). Following the interventions, vaccination coverage increased significantly from 5.8% (22/377) to 19.1% (71/371) in residents and from 1.3% (3/234) to 19.7% (46/233) in HCWs (p < 0.001). During the observational period (2019/20 to 2022/23 seasons), vaccination coverage remained high in residents but decreased in HCWs. Vaccination adherence was significantly higher in residents and HCWs in LTCF 1 compared to the other three LTCFs. Our study suggests that a bundle of educational interventions and enhanced vaccination services can be an effective method for improving influenza vaccination coverage in LTCFs in both residents and HCWs. However, vaccination rates are still well below the recommended targets and further efforts are needed to increase vaccine coverage in our LTCFs.

Poor Prognosis for Puumala Virus Infections Predicted by Lymphopenia and Dyspnea.

We investigated a prospective cohort of 23 patients who had Puumala virus infection in Austria to determine predictors of infection outcomes. We reviewed routinely available clinical and laboratory parameters collected when patients initially sought care. Low absolute lymphocyte count and dyspnea were parameters associated with a severe course of infection.

Treatment options for multidrug-resistant Gram-negatives in urinary tract infections.

PURPOSE OF REVIEW: Infections due to multidrug-resistant (MDR) Gram-negative bacteria are challenging to treat because of limited treatment options and potential side effects of less frequently used anti-infectives. In the past few years, several new antimicrobial agents effective against MDR Gram-negatives have become available. This review focuses on the treatment options for complicated urinary tract infections (cUTIs) caused by MDR Gram-negatives. RECENT FINDINGS: The novel combinations, betalactam or carbapenem and betalactamase inhibitor, ceftazidime/avibactam and meropenem/vaborbactam, are effective for infections caused by KPC-carbapenemase-producing pathogens. Imipenem/relebactam, another carbapenem/betalactamase inhibitor combination, has been approved for the treatment of cUTI. However, data on the efficacy of imipenem/relebactam against carbapenem-resistant pathogens is still limited. Ceftolozane/tazobactam is mainly used for the treatment of MDR Pseudomonas aeruginosa infections. For the treatment of cUTI caused by extended-spectrum betalactamases producing Enterobacterales aminoglycosides or intravenous fosfomycin should be considered. SUMMARY: To ensure prudent use and to avoid the development of resistance to novel anti-infective substances, an interdisciplinary approach, including urologists, microbiologists, and infectious disease physicians, is strongly advised.

Establishing breakpoints for amoxicillin/clavulanate and ampicillin/sulbactam for rapid antimicrobial susceptibility testing directly from positive blood culture bottles.

Introduction. In 2018, EUCAST released guidelines on rapid antimicrobial susceptibility testing (RAST) directly from positive blood culture bottles for selected bacterial species and antimicrobial agents, but not for the commonly used agents amoxicillin/clavulanate (AMC) and ampicillin/sulbactam (SAM).Hypothesis/Gap statement. This work addresses the Enterobacterales RAST capability gap for betalactam/betalactamase inhibitor combinations.Aim. We aimed to determine RAST breakpoints for AMC and SAM for Escherichia coli and Klebsiella pneumoniae after 4 and 6 h of incubation directly from positive blood cultures.Methodology. Blood culture bottles were spiked with clinical isolates of E. coli (n=89) and K. pneumoniae (n=81). RAST was performed according to EUCAST guidelines and zones were read after 4 and 6 h. Breakpoints were defined to avoid very major errors.Results. The proportion of readable zone diameters after 4 h of incubation were 90.8 % in E. coli and 85.8 % in K. pneumoniae isolates. After 6 h of incubation all zone diameters could be read. The proposed breakpoints for E. coli after 6 h of incubation were ≥16 mm S (susceptible), 14-15 mm ATU (area of technical uncertainty) and <14 mm R (resistant) for AMC; ≥15 mm S, 12-14 mm ATU and <12 mm R for SAM; for K. pneumoniae these were ≥16 mm S, 14-15 mm ATU and <14 mm R for AMC; ≥13 mm S, 12 mm ATU, <12 mm R for SAM. Applying our newly set breakpoints, major errors were infrequent (2.6 %).Conclusion. We propose novel AMC and SAM breakpoints for RAST directly from positive blood cultures for reading after 4 and 6 h of incubation.

A Comparison of the Representation of Women in Editor Positions at Major Medical Journals in 2021 vs 2011.

PURPOSE: There continues to be a disparity in the representation of women across medicine, including in editor positions at major medical journals. The authors repeated a study they had conducted in 2011 to compare the representation of women in editor-in-chief and editorial board member positions in 2011 and 2021. METHOD: The authors included in their analysis the 60 journals from their original 2011 study and the top 5 ranked journals by Journal Impact Factor in each of 12 disciplines in 2021. This led to the inclusion of 86 journals. The authors collected the names and genders of the editors-in-chief and editorial board members at these journals, using information provided by the journals and a Google search for the photos and/or pronouns of the remaining editors. They compared results across years (2021 vs 2011), editor positions, disciplines, Journal Impact Factors, and ranks. RESULTS: Twenty-two of the 90 editors-in-chief (24.4%) were women in 2021 compared with 10 of 63 (15.9%) in 2011, an increase of 8.5%. Of the 6,285 editorial board members, 1,756 were women (27.9%) in 2021 compared with 719 of 4,112 (17.5%) in 2011, an increase of 10.4%. Journals with women editors-in-chief gained 3.5 ranks and 9.1 points in Journal Impact Factor on average over this 10-year period, compared with no gain in rank and an increase of 4.7 points in Journal Impact Factor for journals with men editors-in-chief; both are statistically significant differences (P = .045 and P = .016, respectively). CONCLUSIONS: In almost all evaluated disciplines and editor positions, there was an increase in the percentage of women at top-ranked medical journals over a 10-year period. Despite this increase, improvements are still needed to accelerate the currently slow rate of change in these positions to enhance diversity, equity, and inclusion for women in medicine.

European society of clinical microbiology and infectious diseases guidelines for coronavirus disease 2019: an update on treatment of patients with mild/moderate disease.

SCOPE: Despite the large availability of vaccines, coronavirus disease 2019 (COVID-19), induced by severe acute respiratory syndrome coronavirus 2, continues to be a major threat for health-care providers and fragile people. A number of options are now available for outpatients with mild-to-moderate COVID-19 at the risk of disease progression for the prevention of deaths or hospitalization. METHODS: A European Society of Clinical Microbiology and Infectious Diseases COVID-19 guidelines task force was established by the European Society of Clinical Microbiology and Infectious Diseases Executive Committee. A small group was established, half appointed by the chair and the remaining selected based on an open call. Each panel met virtually once a week. For all decisions, a simple majority vote was used. A long list of clinical questions using the population, intervention, comparison, outcome format was developed at the beginning of the process. For each population, intervention, comparison, outcome, two panel members performed a literature search, with a third panelist involved in case of inconsistent results. Voting was based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. RECOMMENDATIONS: In this update, we focus on anti-viral agents, monoclonal antibodies (mAbs) and other treatment options proposed for patients with mild or moderate COVID-19 who are at the risk of hospitalization or death. Although the use of anti-virals is recommended, especially nirmatrelvir/ritonavir and remdesivir or, alternatively, molnupirarvir, the administration of mAbs against the spike protein strictly depends on circulating variants or the ability to test timely for variants and sub-variants. At the time of writing (April-June 2022), the only active mAb was tixagevimab/cilgavimab given the predominance of the Omicron BA.2, BA.3, BA.4 and BA.5 sub-lineages in Europe. However, considering that the epidemiological scenario is extremely dynamic, constant monitoring of variants of concern is mandatory.

Spinal Surgery Site Infection Leading to Implant Loosening Is Influenced by the Number of Prior Operations.

STUDY DESIGN: Retrospective Cohort Study. OBJECTIVES: Spinal surgery site infection and chronic implant infection are possible causes for ongoing pain, implant loosening, and failed back surgery syndrome. Evidence of chronic infection was found in 29.1% of revision cases but is also found in a considerable number of degenerative cases without prior surgery. Infection mechanisms and possible clinical correlations are unclear. METHODS: Retrospective analysis of standardized surgery site screening (swab, tissue samples, implant sonication) in 181 cases without clinical evidence of preoperative surgery site infection. RESULTS: Screening results of cases without prior spinal surgery (n = 49, 10.2% positive) were compared to cases with prior spine surgery without implant placement (e.g. micro discectomy) (n = 21, 23.8% positive), revision cases following singular spinal fusion (n = 73, 23.2% positive), and cases with multiple revisions (n = 38, 50.0% positive). Propionibacterium spp. detection rate increased to 80% in positive cases with multiple revisions. Implants in place during revision surgery had a significantly higher infection rate (32.4%) compared to no implant (14.2%, p = 0.007). Positive cases had a significantly higher pain level prior to surgery compared to negative cases (p = 0.019). Laboratory parameters had no predictive value. Logistic regression revealed that previous spinal surgeries (odds ratio [OR] 1.38 per operation, p < 0.001) and male sex (OR 1.15, p = 0.028) were independent predictive factors for infection. CONCLUSIONS: Previous spinal surgery is a risk factor for chronic surgery site infection, leading to chronic pain, implant loosening, and revision. The presence of Propionibacterium spp. was correlated with chronic implant loosening and was more likely with cumulative surgeries.

ESCMID COVID-19 living guidelines: drug treatment and clinical management.

SCOPE: In January 2021, the ESCMID Executive Committee decided to launch a new initiative to develop ESCMID guidelines on several COVID-19-related issues, including treatment of COVID-19. METHODS: An ESCMID COVID-19 guidelines task force was established by the ESCMID Executive Committee. A small group was established, half appointed by the chair, and the remaining selected with an open call. Each panel met virtually once a week. For all decisions, a simple majority vote was used. A long list of clinical questions using the PICO (population, intervention, comparison, outcome) format was developed at the beginning of the process. For each PICO, two panel members performed a literature search with a third panellist involved in case of inconsistent results. Voting was based on the GRADE approach. QUESTIONS ADDRESSED BY THE GUIDELINE AND RECOMMENDATIONS: A synthesis of the available evidence and recommendations is provided for each of the 15 PICOs, which cover use of hydroxychloroquine, bamlanivimab alone or in combination with etesevimab, casirivimab combined with imdevimab, ivermectin, azithromycin and empirical antibiotics, colchicine, corticosteroids, convalescent plasma, favipiravir, remdesivir, tocilizumab and interferon ß-1a, as well as the utility of antifungal prophylaxis and enoxaparin. In general, the panel recommended against the use of hydroxychloroquine, ivermectin, azithromycin, colchicine and interferon ß-1a. Conditional recommendations were given for the use of monoclonal antibodies in high-risk outpatients with mild-moderate COVID-19, and remdesivir. There was insufficient evidence to make a recommendation for use of favipiravir and antifungal prophylaxis, and it was recommended that antibiotics should not be routinely prescribed in patients with COVID-19 unless bacterial coinfection or secondary infection is suspected or confirmed. Tocilizumab and corticosteroids were recommended for treatment of severe COVID-19 but not in outpatients with non-severe COVID-19. SCOPE: The aim of the present guidance is to provide evidence-based recommendations for management of adults with coronavirus disease 2019 (COVID-19). More specifically, the goal is to aid clinicians managing patients with COVID-19 at various levels of severity including outpatients, hospitalized patients, and those admitted to intensive care unit. Considering the composition of the panel, mostly clinical microbiologists or infectious disease specialists with no pulmonology or intensive care background, we focus only on pharmacological treatment and do not give recommendations on oxygen supplement/support. Similarly, as no paediatricians were included in the panel; the recommendations are only for adult patients with COVID-19. Considering the current literature, no guidance was given for special populations such as the immunocompromised.

Analysis of COVID-19 outbreaks in 3 long-term care facilities in Graz, Austria.

BACKGROUND: Nursing homes and long-term care facilities (LTCF) caring for elderly and chronically ill residents are at high risk to experience severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) outbreaks. We report an outbreak of coronavirus disease 2019 (COVID-19) in 3 LTCFs of the Geriatric Health Centres of Graz, Austria lasting from March 22 to April 14, 2020. AIM: The objectives of our study were: (1) to elucidate contributing factors and transmission pathways of SARS-CoV-2, (2) to analyze symptoms of COVID-19 in the residents and health care workers. METHODS: We carried out a retrospective outbreak analysis. FINDINGS: Thirty-six of /277 residents of 3 LTCFs were infected with SARS-CoV-2. Only a quarter of COVID-19 cases among residents had fever ≥38.1°C and 19% suffered from cough. Six of 36 residents remained asymptomatic. Hospitalization rate was 58% in residents. Overall, 33% (12/36) residents infected with SARS-CoV-2 died. Nineteen of 214 health care workers were tested positive for SARS-CoV-2. Universal rt-PCR testing for SARS-CoV-2 of all residents and health care workers as well as infection control measures contributed to ending the outbreaks. CONCLUSIONS: Delayed recognition of possible COVID-19 cases due to either mild symptoms or symptoms that were perceived as atypical early in the pandemic contributed to the transmission of SARS-CoV-2 in LTCFs. This emphasizes the importance of low-threshold testing in LTCF residents.

Prospective Surveillance of Healthcare-Associated Infections in Residents in Four Long-Term Care Facilities in Graz, Austria.

Healthcare-associated infections (HCAI) are a common cause for residents' mortality and morbidity associated with a significant socio-economic burden. Data on HCAIs in Austrian long-term care facilities are scare. Therefore, we evaluated the incidence rate of HCAIs per 1000 resident days in four LTC facilities in Graz, Austria, characterized the spectrum of HCAIs and the use of antimicrobial substances. We conducted a prospective surveillance study from 1 January to 31 December 2018 in four LTCFs of the Geriatric Health Centre of the City of Graz (total of 388 beds). Nursing staff collected data on HCAIs once a week using an electronic reporting system. During the 12-month surveillance period, 252 infections of 165 residents were recorded. The overall incidence rate of HCAIs was 2.1 per 1000 resident days. Urinary tract infections were the most commonly recorded HCAIs (49%, 124/252, 1.03 per 1000 resident days), followed by skin and soft tissue infections and respiratory tract infections. Beta-lactams (ATC class J01C) were prescribed most frequently (63/212), followed by fluoroquinolones (J01M; 54/212). In conclusion, the overall incidence rate for HCAIs was relatively low at 2.1 per 1000 resident days. Our real-life data can serve as a basis for future antimicrobial stewardship and infection prevention interventions.

Longitudinal Evaluation of Plasma Cytokine Levels in Patients with Invasive Candidiasis.

Interleukin (IL) 17A plays a decisive role in anti-Candida host defense. Previous data demonstrated significantly increased IL-17A values in candidemic patients. We evaluated levels and time courses of IL-17A, and other cytokines suggested to be involved in Candida-specific immunity (IL-6, IL-8, IL-10, IL-17F, IL-22, IL-23, interferon-γ, tumor necrosis factor-α, Pentraxin-related protein 3, transforming growth factor-ß) in patients with invasive candidiasis (IC) compared to bacteremic patients (Staphylococcus aureus, Escherichia coli) and healthy controls (from previous 4 days up to day 14 relative to the index culture (-4; 14)). IL-17A levels were significantly elevated in all groups compared to healthy controls. In IC, the highest IL-17A values were measured around the date of index sampling (-1; 2), compared to significantly lower levels prior and after sampling the index culture. Candidemic patients showed significantly higher IL-17A values compared to IC other than candidemia at time interval (-1; 2) and (3; 7). No significant differences in IL-17A levels could be observed for IC compared to bacteremic patients. Candidemic patients had higher IL-8, IL-10, IL-22, IFN-γ, PTX3 and TNF-α values compared to non-candidemic. Based on the limited discriminating competence between candidemia and bacteremia, IL-17A has to be considered a biomarker for blood stream infection rather than invasive Candida infection.

Acute Liver Failure after Ingestion of Fried Rice Balls: A Case Series of Bacillus cereus Food Poisonings.

Bacillus cereus foodborne intoxications and toxicoinfections are on a rise. Usually, symptoms are self-limiting but occasionally hospitalization is necessary. Severe intoxications with the emetic Bacillus cereus toxin cereulide, which is notably resistant heat and acid during cooking, can cause acute liver failure and encephalopathy. We here present a case series of food poisonings in five immunocompetent adults after ingestion of fried rice balls, which were massively contaminated with Bacillus cereus. The patients developed a broad clinical spectrum, ranging from emesis and diarrhoea to life-threatening acute liver failure and acute tubular necrosis of the kidney in the index patient. In the left-over rice ball, we detected 8 × 106Bacillus cereus colony-forming units/g foodstuff, and cereulide in a concentration of 37 µg/g foodstuff, which is one of the highest cereulide toxin contaminations reported so far from foodborne outbreaks. This report emphasizes the potential biological hazard of contaminated rice meals that are not freshly prepared. It exemplifies the necessity of a multidisciplinary approach in cases of Bacillus cereus associated food poisonings to rapidly establish the diagnosis, to closely monitor critically ill patients, and to provide supportive measures for acute liver failure and-whenever necessary-urgent liver transplantation.

Implementation of rapid antimicrobial susceptibility testing combined with routine infectious disease bedside consultation in clinical practice (RAST-ID): a prospective single-centre study.

OBJECTIVES: Recently, EUCAST released guidelines for rapid antimicrobial susceptibility testing (RAST) directly from positive blood culture bottles. The aim of our prospective single-centre clinical study was to assess the proportion of readable results and errors compared with routine antimicrobial susceptibility testing and the clinical consequences drawn by infectious disease (ID) physicians from RAST results during same-day bedside consultation. METHODS: All positive blood cultures suitable for RAST from January to December 2019 were included and RAST results at 4 and 6 h compared with standard disc diffusion. The real-life impact of RAST on clinical decisions was assessed during same-day ID bedside consultation. RESULTS: The proportion of readable RAST results was significantly higher after 6 h of incubation compared with after 4 h (881/930 versus 642/847; P < 0.0001). Major and very major errors were rare (17/642 after 4 h and 12/881 after 6 h; P = 0.087). ID consultation was performed in 134 patients after the RAST result. Antimicrobial treatment was changed in 73 patients and 84 additional measures (i.e. imaging studies, surgery, additional resistance testing) were ordered in 62 patients. CONCLUSIONS: RAST according to EUCAST methods was easy to implement with a low number of major and very major errors after 6 h of incubation. ID physicians performing bedside consultations frequently used this information to change antimicrobial treatment and recommended additional measures.

An epidemic CC1-MRSA-IV clone yields false-negative test results in molecular MRSA identification assays: a note of caution, Austria, Germany, Ireland, 2020.

We investigated why a clinical meticillin-resistant Staphylococcus aureus (MRSA) isolate yielded false-negative results with some commercial PCR tests for MRSA detection. We found that an epidemic European CC1-MRSA-IV clone generally exhibits this behaviour. The failure of the assays was attributable to a large insertion in the orfX/SCCmec integration site. To ensure the reliability of molecular MRSA tests, it is vital to monitor emergence of new SCCmec types and junction sites.