Burden of community-associated Clostridioides difficile infection in southeastern United States: a population-based study.

OBJECTIVES: This cross-sectional population-based study aims to determine overall incidence rate of Clostridioides difficile infection (CDI) in the State of South Carolina and provide an estimated cost of hospitalization due to community-associated CDI (CA-CDI). METHODS: All CDI cases in South Carolina were identified through National Healthcare Safety Network (NHSN) and the South Carolina Infectious Disease and Outbreak Network (SCION) from January 1, 2015 to June 30, 2016, excluding infants < 1 year of age. RESULTS: During the 18-month study period, 10,254 CDI events were identified in South Carolina residents with an overall incidence rate of 139/100,000 person-years. Over one-half of CDI cases were CA-CDI (5192; 51%) with an incidence rate of 71/100,000 person-years. Among patients with CA-CDI, 2127 (41%) required hospitalization with a median length of stay of 5 days. The annual burden of CA-CDI in South Carolina was estimated to be 9282 hospital days and $16,217,295 in hospitalization costs. CONCLUSION: The incidence rate of CA-CDI in South Carolina has surpassed both community-onset healthcare facility associated and hospital-onset CDI combined. The heavy burden of CA-CDI justifies dedication of public health resources to combat CDI in ambulatory settings, through antimicrobial stewardship initiatives.

Syndrome-specific versus prospective audit and feedback interventions for reducing use of broad-spectrum antimicrobial agents.

BACKGROUND: Antimicrobial use (AU) of antipseudomonal ß-lactams (APBL) has significantly increased over the past decade in US hospitals. This retrospective cohort study compares 2 common antimicrobial stewardship strategies, syndrome-specific interventions and antimicrobial postprescription prospective audit and feedback (PAF), in reducing AU of APBL at a large community-teaching hospital. METHODS: Four antimicrobial stewardship interventions targeting APBL were serially introduced, including 2 syndrome-specific interventions (bloodstream and intra-abdominal infections) and 2 PAF interventions (carbapenems and piperacillin/tazobactam). Multivariable linear regression was used to examine overall AU of APBL and audited antimicrobial agents. RESULTS: Overall AU of APBL declined from 92.4-69.1 days of therapy (DOT) per 1,000 patient-days between February 2013 and July 2017 (P < .001). Both syndrome-specific interventions were associated with significant reduction in AU of APBL (-7.7 [95% confidence interval (CI): -11.5, -4.0] and -6.0 [95% CI: -9.7, -2.3] DOT per 1,000 patient-days) for bloodstream and intra-abdominal infections, respectively). No significant change in overall AU of APBL was observed after implementation of PAF interventions for carbapenems (-1.4 [95% CI: -7.4, 4.6] DOT per 1,000 patient-days) or piperacillin/tazobactam (0.9 [95% CI: -3.7, 5.4] DOT per 1,000 patient-days). CONCLUSIONS: Implementation of syndrome-specific interventions was followed by significant reduction in AU of APBL in this population. Despite reducing AU of targeted agents, neither PAF intervention contributed to overall observed decline in APBL use, likely due to compensatory increase in using other APBL.

Common Bacterial and Viral Infections: Review of Management in the Pregnant Patient.

OBJECTIVE: To review the treatment of common bacterial and viral infections occurring in the pregnant patient. DATA SOURCES: A literature search of MEDLINE was performed (inception to October 2018). The Centers for Disease Control and Prevention website was utilized for additional information. STUDY SELECTION AND DATA EXTRACTION: Relevant English-language studies and those conducted in humans were considered. DATA SYNTHESIS: ß-Lactams alone or in combination are the preferred treatment for many common infections in pregnancy, such as urinary tract infections, pelvic inflammatory disease (PID), gonococcal infections, syphilis, chancroid, upper- and lower-respiratory-tract infections, certain gastrointestinal infections, Group B Streptococcus, listeriosis, and intrauterine inflammation or infection. Macrolides, particularly azithromycin, are also utilized for the treatment of PID, chlamydia, gonococcal infections, chancroid, community-acquired pneumonia, and certain gastrointestinal infections. Other antibiotics or antivirals such as vancomycin, aminoglycosides, metronidazole, nitrofurantoin, fosfomycin, acyclovir, valacyclovir, and oseltamivir are included in the preferred therapy for some common bacterial and viral infections in pregnant patients as well. Relevance to Patient Care and Clinical Practice: This review synthesizes available evidence of treatments of common infections in pregnancy and provides a concise summary to guide clinicians on empirical treatment during pregnancy. CONCLUSIONS: There are limited data on clinical outcomes in pregnant patients with common bacterial and viral infections. Empirical management decisions require balance of benefit and risk to both mother and infant. Although few clinical practice guidelines have quality evidence for strong recommendations in this population, clinicians should weigh antimicrobial dosing, pharmacokinetics, safety, and established effectiveness to optimize antimicrobial therapy in pregnancy.

Role of Early De-escalation of Antimicrobial Therapy on Risk of Clostridioides difficile Infection Following Enterobacteriaceae Bloodstream Infections.

BACKGROUND: There is a paucity of data on the effect of early de-escalation of antimicrobial therapy on rates of Clostridioides difficile infection (CDI). This retrospective cohort study evaluated impact of de-escalation from antipseudomonal ß-lactam (APBL) therapy within 48 hours of Enterobacteriaceae bloodstream infections (BSIs) on 90-day risk of CDI. METHODS: Adult patients hospitalized for >48 hours for treatment of Enterobacteriaceae BSI at Palmetto Health hospitals in Columbia, South Carolina, from 1 January 2011 through 30 June 2015 were identified. Multivariable Cox proportional hazards regression was used to examine time to CDI in patients who received >48 hours or ≤48 hours of APBL for empirical therapy of Enterobacteriaceae BSI after adjustment for the propensity to receive >48 hours of APBL. RESULTS: Among 808 patients with Enterobacteriaceae BSI, 414 and 394 received >48 and ≤48 hours of APBL, respectively. Incidence of CDI was higher in patients who received >48 hours than those who received ≤48 hours of APBL (7.0% vs 1.8%; log-rank P = .002). After adjustment for propensity to receive >48 hours of APBL and other variables in the multivariable model, receipt of >48 hours of APBL (hazard ratio [HR], 3.56 [95% confidence interval {CI}, 1.48-9.92]; P = .004) and end-stage renal disease (HR, 4.27 [95% CI, 1.89-9.11]; P = .001) were independently associated with higher risk of CDI. CONCLUSIONS: The empirical use of APBL for >48 hours was an independent risk factor for CDI. Early de-escalation of APBL using clinical risk assessment tools or rapid diagnostic testing may reduce the incidence of CDI in hospitalized adults with Enterobacteriaceae BSIs.

Impact of an antifungal stewardship intervention on optimization of candidemia management.

BACKGROUND: Candidemia represents a leading cause of healthcare-associated bloodstream infections with significant morbidity and mortality. Previous studies have demonstrated that comprehensive care bundles improve candidemia management but are time-consuming. OBJECTIVE: To determine the impact of a one-time targeted candidemia intervention on time to initiation of adequate therapy compared to standard of care. METHODS: This Institutional Review Board (IRB)-approved, quasi-experiment evaluated a targeted candidemia intervention involving a single phone call to the primary team providing recommendations for care. Daily follow-up was provided by the infectious diseases (ID) consult service. Two time periods were evaluated: pre-intervention (01 August 2012 to 31 July 2014) and post-intervention (01 October 2014 to 30 September 2016). The primary endpoint was time to adequate antifungal therapy (TTx) in the business hours (6 a.m. to 6 p.m. Monday through Friday) population (BHP). Secondary endpoints were TTx in the total population as well as infection-related length of stay (IF-LOS) and compliance with quality indicators (composite endpoint: ophthalmology (OPH) consult, repeat cultures, and ⩾14 days of adequate therapy). RESULTS: In all, 117 patients were included (pre-intervention = 50, post-intervention = 67, BHP = 51). TTx decreased from 2 h 57 m to 2 h 12 m (p = 0.094) in the BHP and 3 h 30 m to 2 h 9 m (p = 0.021) in the total population. There was no difference in IF-LOS (p = 0.797), compliance with quality indicators (p = 0.343), or in-hospital mortality (p = 0.761). Post-intervention, there were more ID and OPH consults (p < 0.001). CONCLUSIONS: Our one-time candidemia intervention did not statistically decrease time to adequate therapy in the BHP, but did in the total population. No differences were found for other clinical outcomes, except increases in ID and OPH consults. Further studies are needed to examine whether a one-time intervention is non-inferior to a more comprehensive care bundle.

Time-Kill Analysis of Ceftolozane/Tazobactam Efficacy Against Mucoid Pseudomonas aeruginosa Strains from Cystic Fibrosis Patients.

INTRODUCTION: Mucoid Pseudomonas aeruginosa (MP) strains in cystic fibrosis (CF) patients are thought to initiate the chronic infection stage of CF and are associated with pulmonary function decline. OBJECTIVES: The purpose of this study was to assess the susceptibility of MP strains to ceftolozane/tazobactam and the efficacy of ceftolozane/tazobactam against MP strains compared with those for standard-of-care antipseudomonal antibiotics. METHODS: Ten clinical isolates of MP from CF patients were tested for susceptibility with Etest and time-kill analysis with ceftolozane/tazobactam compared with ceftazidime, cefepime, ciprofloxacin, meropenem, tobramycin, and polymyxin B. The physiologic free peak concentrations were used in the time-kill experiments. RESULTS: Ceftolozane/tazobactam minimum inhibitory concentrations ranged from 0.032 to 1.5 mg/L. In the time-kill analysis, the mean starting inoculum for the isolates was 6.29 ± 0.22 log10 colony forming units (CFU) per milliliter. On average, ceftolozane/tazobactam, cefepime, ciprofloxacin, meropenem, tobramycin, and polymyxin B all demonstrated bactericidal activity. With all isolates taken into account, polymyxin B, tobramycin, meropenem, and ceftolozane/tazobactam 3 g were the most potent, with reductions in inoculum of 5.07 ± 0.45, 4.58 ± 2.2, 4.76 ± 0.71, and 4.17 ± 0.94 log10 CFU/mL, respectively. Ceftolozane/tazobactam 1.5 g, cefepime, and ciprofloxacin reduced the starting inoculum by 3.74 ± 0.99, 3.42 ± 1.4, and 3.23 ± 2.0 log10 CFU/mL, respectively. Despite 90% susceptibility, ceftazidime was bactericidal against seven of ten strains, with an average reduction in starting inoculum of 2.91 ± 2.2 log10 CFU/mL. CONCLUSION: Ceftolozane/tazobactam activity against MP strains derived from CF patients was comparable to that of standard-of-care agents at both the 1.5-g dose and the 3-g dose. Further in vitro modeling and clinical trials are warranted.

Successful Treatment of Necrotizing Fasciitis and Streptococcal Toxic Shock Syndrome with the Addition of Linezolid.

Necrotizing fasciitis is a deep-seated subcutaneous tissue infection that is commonly associated with streptococcal toxic shock syndrome (TSS). Surgical debridement plus penicillin and clindamycin are the current standard of care. We report a case of necrotizing fasciitis and streptococcal TSS where linezolid was added after a failure to improve with standard therapy. Briefly after isolation of Streptococcus pyogenes from tissue cultures, the patient underwent two surgical debridement procedures and was changed to standard of care therapy. While the patient was hemodynamically stable, the patient's wounds, leukocytosis, and thrombocytopenia all progressively worsened. After initiation of linezolid, the patient slowly improved clinically. The present report is the first to highlight the role of linezolid in streptococcal necrotizing fasciitis and TSS not improving with standard therapy.