Impact of Reported Beta-Lactam Allergy on Inpatient Outcomes: A Multicenter Prospective Cohort Study.

BACKGROUND: Reported allergy to beta-lactam antibiotics is common and often leads to unnecessary avoidance in patients who could tolerate these antibiotics. We prospectively evaluated the impact of these reported allergies on clinical outcomes. METHODS: We conducted a trainee-led prospective cohort study to determine the burden and clinical impact of reported beta-lactam allergy on patients seen by infectious diseases consultation services at 3 academic hospitals. The primary outcome was a composite measure of readmission for the same infection, acute kidney injury, Clostridium difficile infection, or drug-related adverse reactions requiring discontinuation. Predictors of interest were history of beta-lactam allergy and receipt of preferred beta-lactam therapy. RESULTS: Among 507 patients, 95 (19%) reported beta-lactam allergy; preferred therapy was a beta-lactam in 72 (76%). When beta-lactam therapy was preferred, 25 (35%) did not receive preferred therapy due to their report of allergy even though 13 (52%) reported non-severe prior reactions. After adjustment for confounders, patients who did not receive preferred beta-lactam therapy were at greater risk of adverse events (adjusted odds ratio [aOR], 3.1; 95% confidence interval [CI], 1.28-7.89) compared with those without reported allergy. In contrast, patients who received preferred beta-lactam therapy had a similar risk of adverse events compared with patients not reporting allergy (aOR, 1.33; 95% CI, .62-2.87). CONCLUSIONS: Avoidance of preferred beta-lactam therapy in patients who report allergy is associated with an increased risk of adverse events. Development of inpatient programs aimed at accurately identifying beta-lactam allergies to safely promote beta-lactam administration among these patients is warranted.

An educational forum to engage infectious diseases and microbiology residents in resource stewardship modelled after the Choosing Wisely campaign.

BACKGROUND: Rising costs present a major threat to the sustainability of health care delivery. Resource stewardship is increasingly becoming an expected competency of physicians. The Choosing Wisely framework was used to introduce resource stewardship at a national educational retreat for infectious disease and microbiology residents. METHODS: During the 2014 Annual Canadian Infectious Disease and Microbiology Resident Retreat in Toronto, Ontario, infectious disease (n=50) and microbiology (n=17) residents representing 11 Canadian universities from six provinces, were invited to participate in a modified Delphi panel. Participants were asked, in advance of the retreat, to submit up to five practices that infectious disease and microbiology specialists should not routinely perform due to lack of proven benefit(s) and/or potential harm to patients. Submissions were discussed in small and large group forums using an iterative approach involving electronic polling until consensus was reached for five practices. A finalized list was created for both educational purposes and for residents to consider enacting; however, it was not intended to replace formal society-endorsed statements. A follow-up survey at two-months was conducted. RESULTS: Consensus was reached by the residents regarding five low-value practices within the purview of infectious diseases and microbiology physicians. After the retreat, 20 participants (32%) completed the follow-up survey. The majority of respondents (75%) believed that the session was at least as relevant as other sessions they attended at the retreat, including 95% indicating that at least some of the material discussed was new to them. Since returning to their home institutions, nine (45%) respondents have incorporated what they learned into their daily practice; four (20%) reported that they have considered initiating a project related to the session; and one (5%) reported having initiated a project. CONCLUSIONS: The present educational forum demonstrated that trainees can become actively engaged in the identification and discussion of low-value practices. Embedding residence training programs with resource stewardship education will be necessary to improve the value of care offered by the future members of our profession.

HISTORIQUE: Les coûts croissants représentent une menace importante pour la pérennité des soins de santé. De plus en plus, on s'attend que les médecins aient les compétences nécessaires pour gérer les ressources. Lors d'une journée de réflexion nationale pour les résidents en infectiologie et en microbiologie, la gestion des ressources a été abordée conformément au cadre Choosing Wisely. MÉTHODOLOGIE: Pendant la journée de réflexion canadienne annuelle de 2014 pour les résidents en infectiologie et en microbiologie tenue à Toronto, en Ontario, des résidents en infectiologie (n=50) et en microbiologie (n=17) représentant 11 universités canadiennes réparties dans six provinces ont été invités à participer à un groupe Delphi modifié. Avant la journée de réflexion, ils ont été invités à soumettre jusqu'à cinq pratiques que les spécialistes de l'infectiologie ou de la microbiologie ne devraient pas effectuer systématiquement parce que leurs avantages ne sont pas démontrés ou qu'elles comportent des risques potentiels pour les patients. Ils ont examiné ces pratiques lors de forums en petits et grands groupes selon une méthode itérative par sondage électronique, jusqu'à atteindre un consensus pour cinq pratiques. Une liste définitive a été créée pour des besoins d'éducation et pour que les résidents envisagent de la respecter. Cette liste ne visait toutefois pas à remplacer les documents officiels approuvés par la Société. Un sondage de suivi a été effectué au bout de deux mois. RÉSULTATS: Les résidents sont parvenus à un consensus sur cinq pratiques de faible valeur qui relèvent des médecins en infectiologie et en microbiologie. Après la journée de réflexion, 20 participants (32 %) ont rempli le sondage de suivi. La majorité d'entre eux (75 %) trouvaient que cette séance était au moins aussi pertinente que les autres séances auxquelles ils avaient assisté pendant la journée de réflexion, et 95 % ont indiqué qu'au moins une partie de ce qui avait été abordé était nouveau pour eux. Depuis leur retour au sein de leur établissement, neuf (45 %) répondants avaient intégré ce qu'ils avaient appris à leur pratique, quatre (20 %) ont déclaré avoir envisagé un projet lié à la séance et un (5 %) a affirmé avoir lancé un projet. CONCLUSIONS: Le présent forum d'éducation a démontré que les résidents peuvent s'investir pour cerner les pratiques de faible valeur et en discuter. Il faudra intégrer la gérance de l'éducation aux programmes de résidence pour améliorer la valeur des soins offerts par les futurs membres de notre profession.

Cardiovascular Risk Factors and In-hospital Mortality in Acute Coronary Syndromes: Insights From the Canadian Global Registry of Acute Coronary Events.

BACKGROUND: There are conflicting data regarding the relationship between the number of modifiable traditional risk factors and prognosis in acute coronary syndromes (ACS). This controversy might in part be explained by the differential use of prehospital medications. METHODS: Using data from the Canadian, multicentre Global Registry of Acute Coronary Events (GRACE) (1999-2008), we stratified 13,686 ACS patients into 3 groups (0, 1-2, vs 3-4 risk factors) and compared their baseline characteristics, in-hospital treatments, and outcomes. Multivariable logistic regressions were performed to adjust for the components of the GRACE risk score and preadmission statin and acetylsalicylic acid (ASA) use. RESULTS: Among these patients (ST-elevation myocardial infarction 28.3%), 14.5%, 62.6%, and 22.9% had 0, 1-2, and 3-4 risk factors, respectively. Patients with fewer risk factors were less likely to be on ASA, statin, and other prehospital medications. Unadjusted in-hospital mortality was significantly different across risk factor groups (4.9%, 3.0%, and 3.1% for 0, 1-2, and 3-4 risk factor groups, respectively, P for trend = 0.002). This difference was no longer significant after adjusting for the components of the GRACE risk score (P for trend = 0.088) and further adjusting for preadmission statin and ASA use (P for trend = 0.96). For in-hospital mortality, there was no significant interaction between risk factor categories and ACS type (P = 0.26). CONCLUSIONS: The lower mortality observed in patients with ACS with more risk factors may be partially attributed to the protective effect of prehospital ASA and statin use. The number of risk factors does not provide incremental prognostic value beyond the validated GRACE risk score.

Systematic deletion analyses of the fla genes in the flagella operon identify several genes essential for proper assembly and function of flagella in the archaeon, Methanococcus maripaludis.

The archaeal flagellum is a unique motility apparatus in the prokaryotic domain, distinct from the bacterial flagellum. Most of the currently recognized archaeal flagella-associated genes fall into a single fla operon that contains the genes for the flagellin proteins (two or more genes designated as flaA or flaB), some variation of a set of conserved proteins of unknown function (flaC, flaD, flaE, flaF, flaG and flaH), an ATPase (flaI) and a membrane protein (flaJ). In addition, the flaD gene has been demonstrated to encode two proteins: a full-length gene product and a truncated product derived from an alternate, internal start site. A systematic deletion approach was taken using the methanogen Methanococcus maripaludis to investigate the requirement and a possible role for these proposed flagella-associated genes. Markerless in-frame deletion strains were created for most of the genes in the M. maripaludis fla operon. In addition, a strain lacking the truncated FlaD protein [FlaD M(191)I] was also created. DNA sequencing and Southern blot analysis confirmed each mutant strain, and the integrity of the remaining operon was confirmed by immunoblot. With the exception of the DeltaFlaB3 and FlaD M(191)I strains, all mutants were non-motile by light microscopy and non-flagellated by electron microscopy. A detailed examination of the DeltaFlaB3 mutant flagella revealed that these structures had no hook region, while the FlaD M(191)I strain appeared identical to wild type. Each deletion strain was complemented, and motility and flagellation was restored. Collectively, these results demonstrate for first time that these fla operon genes are directly involved and critically required for proper archaeal flagella assembly and function.