Adherence to clinical practice guidelines for the treatment of candidemia at a Veterans Affairs Medical Center.

OBJECTIVES: The primary objective of this study was to examine the appropriateness of candidemia management at a Veterans Affairs Medical Center as recommended by the 2009 Infectious Diseases Society of America (IDSA) guidelines for treatment of Candida infections. METHODS: A retrospective analysis of 94 adult patients with blood cultures positive for Candida spp. was performed. Patients were stratified by severity of disease into two groups: non-neutropenic, mild-moderate disease (Group 1, n = 54, 56%) and non-neutropenic, moderate-severe disease (Group 2, n = 40, 42%). RESULTS: Adherence to the IDSA recommendations for recommended antifungal drug, dose, and duration of therapy was low in both groups (16.7% in Group 1 and 17.5% in Group 2). Although adherence was not associated with higher clinical resolution of infection (P = 0.111), it was associated with a significantly lower mortality rate (P = 0.001) when compared to variance from the guidelines at 6 weeks. CONCLUSION: Although adherence to published guidelines for treating patients with candidemia was suboptimal at our institution, patients that were managed based on the guidelines had a statistically lower mortality rate.

Significant publications on infectious diseases pharmacotherapy in 2014.

PURPOSE: The most important articles on infectious diseases (ID) pharmacotherapy published in the peer-reviewed literature in 2014, as nominated and selected by panels of pharmacists and others with ID expertise, are summarized. SUMMARY: Members of the Houston Infectious Diseases Network were asked to nominate articles published in 2014 from prominent peer-reviewed journals that were felt to have a major impact in the field of ID pharmacotherapy. A list of 19 nominated articles on general ID-related topics and 9 articles specifically related to human immunodeficiency virus (HIV) infection or acquired immunodeficiency syndrome (AIDS) was compiled. In a national online survey, members of the Society of Infectious Diseases Pharmacists (SIDP) were asked to select from the list 10 general ID articles believed to have made a significant contribution to the field of ID pharmacotherapy and 1 article contributing to HIV/AIDS pharmacotherapy. Of the 291 SIDP members surveyed, 134 (46%) and 56 (19%) participated in the selection of general ID-related articles and HIV/AIDS-related articles, respectively. The 11 highest-ranked papers (10 general ID-related articles, 1 HIV/AIDS-related article) are summarized here. CONCLUSION: With the vast number of articles published each year, it is difficult to remain up-to-date on current, significant ID pharmacotherapy publications. This review of significant publications in 2014 may be helpful by lessening this burden.

In vitro activity and durability of a combination of an antibiofilm and an antibiotic against vascular catheter colonization.

Catheter-associated infections can cause severe complications and even death. Effective antimicrobial modification of catheters that can prevent device colonization has the potential of preventing clinical infection. We studied in vitro the antimicrobial activities of central venous catheters impregnated with N-acetylcysteine (NAC), an antibiofilm agent, and a broad-spectrum antibiotic against a range of important clinical pathogens. NAC-levofloxacin-impregnated (NACLEV) catheters were also evaluated for their antiadherence activity. NACLEV catheters produced the most active and durable antimicrobial effect against both Gram-positive and Gram-negative isolates and significantly reduced colonization (P < 0.0001) by all tested pathogens compared to control catheters. These in vitro results suggest that this antimicrobial combination can potentially be used to combat catheter colonization and catheter-associated infection.

Inappropriate treatment of catheter-associated asymptomatic bacteriuria in a tertiary care hospital.

BACKGROUND: Evidence-based guidelines state that asymptomatic bacteriuria is not a clinically significant condition in men and nonpregnant women and that treatment is unlikely to confer clinical benefit. We hypothesized that, among patients with indwelling catheters or condom collection systems, many who receive a diagnosis of and are treated for catheter-associated urinary tract infection (CAUTI) actually have asymptomatic bacteriuria and, therefore, that antibiotic therapy is inappropriate. METHODS: We reviewed all urine culture results at a veterans affairs medical center during a 3-month period. Cultures yielding 10(4) colony-forming units/mL were included if the urine had been collected from a hospitalized patient with an indwelling (Foley) catheter or a condom collection system. We applied standardized definitions to determine whether the episode represented catheter-associated asymptomatic bacteriuria (CAABU) or CAUTI. Antibiotic therapy was considered appropriate for patients who met criteria for symptomatic UTI. RESULTS: Overall, 280 episodes met criteria for inclusion: 164 CAABU and 116 CAUTI. Of the 164 episodes of CAABU, 111 (68%) were managed appropriately (no treatment), whereas 53 (32%) were treated with antibiotics (inappropriate treatment). In multivariate analysis, older patient age, having predominantly gram-negative bacteriuria, and higher urine white blood cell count were significantly associated with inappropriate treatment of CAABU (P < .05, by logistic regression). CONCLUSIONS: Better recognition of CAABU and the distinction between this condition and CAUTI, consistent with evidence-based guidelines, may play a key role in reducing unneeded antibiotic usage in hospitalized patients.

Association of proton-pump inhibitors with outcomes in Clostridium difficile colitis.

PURPOSE: The role of concurrent use of proton-pump inhibitors (PPIs) in the outcomes of treatment for Clostridium difficile colitis was studied. Methods. The records of inpatients at a large Veterans Affairs medical center in whom C. difficile colitis was diagnosed between June 2004 and July 2005 were retrospectively reviewed. Data collected included patient characteristics at baseline, antibiotic therapy prescribed before and during therapy for C. difficile colitis, concurrent treatment with a PPI, response to therapy for C. difficile colitis, and recurrence of the disease in the 90 days after symptoms resolved. Outcomes of therapy were classified as cures, treatment failures, or disease recurrences. RESULTS: A total of 140 patients (138 men and 2 women) were included in the study. Ninety-seven (69%) of patients received a PPI and 43 (31%) did not. Of patients receiving a PPI, 37 (38%) were cured of C. difficile colitis, 20 (21%) did not respond to therapy, and 40 (41%) had disease recurrence. Among the non-PPI patients, 27 (63%) were cured, 9 (21%) did not respond, and 7 (16%) had recurrence. Patients receiving PPIs were 4.17 times as likely to have recurrence as their counterparts who did not. CONCLUSION: PPI therapy was associated with an increased risk of recurrent C. difficile colitis.

Vancomycin-induced elevation of liver enzyme levels.

OBJECTIVE: To report a case of oral vancomycin-induced elevation of liver enzyme levels. CASE SUMMARY: A 57-year-old man with multiple medical conditions requiring systemic antibiotic therapy developed numerous Clostridium difficile-associated enterocolitis episodes. The patient did not respond adequately to oral metronidazole, as evidenced by his continuing diarrhea. He was treated with oral vancomycin on 5 separate occasions (with doses from 125 to 500 mg/day), each of which resulted in significant elevations in alanine aminotransferase (to 371 U/L) and aspartate aminotransferase (to 203 U/L) levels. The elevations resolved on each occasion with discontinuation of vancomycin. DISCUSSION: Vancomycin, a glycopeptide antibiotic, has primary activity against gram-positive bacteria. Oral vancomycin can be used for the treatment of C. difficile-associated enterocolitis in patients who fail to respond to or are intolerant to metronidazole therapy. Oral vancomycin has very poor bioavailability and, as of May 4, 2006, has not been associated with hepatic toxicity. Inflammatory bowel disease processes can result in increased absorption of oral vancomycin. CONCLUSIONS: This is the first reported case of oral vancomycin-induced elevation of hepatic enzyme levels. Use of the Naranjo probability scale indicated that this was a probable adverse drug-associated event.