Antimicrobial prescribing after rapid influenza PCR implementation in the emergency department.

INTRO: Influenza shares common symptoms with bacterial pneumonia, which may result in unnecessary antibiotic prescriptions in the emergency department (ED) when the diagnosis is unknown. Rapid influenza polymerase chain reaction (PCR) tests have reduced turnaround times compared to standard multiplex PCR respiratory panels allowing for earlier diagnosis, which may improve antimicrobial stewardship outcomes in the ED. This study aims to compare antibiotic and antiviral use before and after deployment of the rapid influenza PCR in the ED. METHODS: This single-center, retrospective, cohort study included pediatric and adult patients discharged from the ED with a positive influenza test using a standard multiplex PCR respiratory panel (January 2017 - July 2019) or rapid PCR (July 2019 - February 2020). The primary endpoint was number of antibiotic prescriptions pre- and post-implementation of the rapid influenza PCR in the ED. Secondary endpoints included number of antiviral prescriptions, duration of antimicrobial therapy, test turnaround time, ED length of stay, 30-day readmission, and adverse events. A multivariable logistic regression evaluated patient factors associated with antimicrobial prescribing. RESULTS: A total of 620 positive influenza results were identified with 280 patients (standard multiplex PCR = 33; rapid PCR = 247) meeting inclusion criteria. Patients were less likely to be prescribed antibiotics (39.4% vs 8.9%, OR 0.15, 95% CI 0.067-0.34) and more likely to be prescribed antivirals (24.2% vs 61.1%, OR 4.92, 95% CI 2.13-11.34) with the rapid influenza PCR. Rapid influenza PCR significantly reduced ED length of stay (4.9 vs 3.4 h, p < 0.01) and test turnaround time (27 h vs 3.5 h, p < 0.01). Patients at high risk for complications associated with influenza were more likely to be prescribed antiviral therapy (22.7% vs 67.8%, OR 7.16, 95% CI 2.52-20.40). Based on the regression analysis conducted, asthma, (OR 3.5, 95% CI 1.48-8.26), immunosuppression (OR 9.6, 95% CI 1.18-78.2), and age <5 years old (OR 3.1, 95% CI 1.80-5.45) were predictors of antiviral prescribing. CONCLUSION: Implementation of a rapid influenza PCR in the ED reduced antibiotic use and optimized antiviral therapy for patients with influenza including those at higher risk of complications.

Case series of cefiderocol for salvage therapy in carbapenem-resistant Gram-negative infections.

PURPOSE: This case series describes real-world utilization of cefiderocol and associated clinical outcomes in the setting of carbapenem-resistant Gram-negative bacterial infections. METHODS: Adult hospitalized patients administered at least 5 days of cefiderocol as definitive treatment from October 1, 2020 to September 16, 2021 were included in this retrospective cohort analysis. The primary outcome was clinical success defined as a composite of 30 day survival, resolution of infection, and absence of 30 day recurrence of the same organism. RESULTS: Among 24 patients, pneumonia (19, 79%) was the most common source of infection with Acinetobacter baumannii (14, 58%) and P. aeruginosa (10, 42%) as the predominant organisms isolated. Cefiderocol monotherapy was used as definitive treatment in 16 (67%) patients. Eleven patients (46%) met clinical success. Thirty-day mortality occurred in ten (42%) patients while seven (29%) patients had recurrence of infection. Thirteen out of 21 total isolates (62%) tested for susceptibility were deemed susceptible. Of the 16 patients with available susceptibility, 9 (56%) had an infection where all isolated organisms were susceptible to cefiderocol. CONCLUSIONS: Our results provide additional insight into the in vivo activity of cefiderocol. Cefiderocol remains a salvage option for carbapenem-resistant Gram-negative organisms.

Oral fluoroquinolones for definitive treatment of gram-negative bacteremia in cancer patients.

PURPOSE: Bloodstream infections (BSI) are significant causes of morbidity and mortality in cancer patients. These patients often receive 10 to 14 days of intravenous (IV) antibiotics. The objective of this study was to compare the outcomes of cancer patients transitioned from IV to oral (PO) therapy compared to continuation of IV treatment. METHODS: This was a single-center, retrospective cohort study of hospitalized adult cancer patients with gram-negative bacteremia. Patients transitioned to a PO fluoroquinolone (FQ) within 5 days were allocated to the IV-to-PO group, while the remaining patients comprised the IV group. The primary outcome was the composite of treatment failure, defined as infection-related readmission, infection recurrence, or inpatient mortality. A multivariable logistic regression model was constructed to account for confounding variables. Secondary outcomes assessed included infection-related length of stay (LOS), hospital LOS, and adverse events, such as Clostridioides difficile infection and catheter-related complications. RESULTS: The IV-to-PO group included 78 patients, while the remaining 133 patients were allocated to the IV group. Differences at baseline included more hematologic malignancy, neutropenia, ICU admissions, and higher Pitt bacteremia scores in the IV group. The rate of treatment failure was significantly higher in the IV group (24% vs 9%; p < 0.01), which persisted in the logistic regression (aOR 3.5, 95% CI 1.3-9.1). The IV-to-PO group had decreased infection-related and hospital length of stay, as well as fewer catheter-related complications. CONCLUSIONS: The use of PO FQ may be considered for the definitive treatment of uncomplicated Enterobacterales BSI in cancer patients.

Fluoroquinolone versus Beta-Lactam Oral Step-Down Therapy for Uncomplicated Streptococcal Bloodstream Infections.

Fluoroquinolones (FQs) are often preferred as oral step-down therapy for bloodstream infections (BSIs) due to favorable pharmacokinetic parameters; however, they are also associated with serious adverse events. The objective of this study was to compare clinical outcomes for patients who received an oral FQ versus an oral beta-lactam (BL) as step-down therapy for uncomplicated streptococcal BSIs. This multicenter, retrospective cohort study analyzed adult patients who completed therapy with an oral FQ or BL with at least one blood culture positive for a Streptococcus species from 1 January 2014 to 30 June 2019. The primary outcome was clinical success, defined as the lack of all-cause mortality, recurrent BSI with the same organism, and infection-related readmission at 90 days. A multivariable logistic regression model for predictors of clinical failure was conducted. A total of 220 patients were included, with 87 (40%) receiving an FQ and 133 (60%) receiving a BL. Step-down therapy with an oral BL was noninferior to an oral FQ (93.2% versus 92.0%; mean difference, 1.2%; 90% confidence interval [CI], -5.2 to 7.8). No differences were seen in 90-day mortality, 90-day recurrent BSI, 90-day infection-related readmission, or 90-day incidence of Clostridioides difficile-associated diarrhea. Predictors of clinical failure included oral step-down transition before day 3 (odds ratio [OR] = 5.18; 95% CI, 1.21, 22.16) and low-dose oral step-down therapy (OR = 2.74; 95% CI, 0.95, 7.90). Our results suggest that oral step-down therapy for uncomplicated streptococcal BSI with a BL is noninferior to an FQ.

Impact of Mandatory Infectious Diseases Consultation and Real-time Antimicrobial Stewardship Pharmacist Intervention on Staphylococcus aureus Bacteremia Bundle Adherence.

BACKGROUND: The purpose of this study was to evaluate the impact of infectious diseases consultation (IDC) and a real-time antimicrobial stewardship (AMS) review on the management of Staphylococcus aureus bacteremia (SAB). METHODS: This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at 7 hospitals. Outcomes were compared between 3 time periods: before mandatory IDC and AMS review (period 1), after mandatory IDC and before AMS review (period 2), and after mandatory IDC and AMS review (period 3). The primary outcome was bundle adherence, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary end points included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality. RESULTS: A total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n = 241/371), 54% in period 2 (n = 47/87), and 76% in period 3 (n = 92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37-0.93; P = .02) and period 2 (OR, 0.37; 95% CI, 0.20-0.67; P = .0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < .001), source control (34% vs 45% vs 45%; P = .04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = .01). No differences were noted for readmission or mortality. CONCLUSIONS: The addition of AMS pharmacist review to mandatory IDC was associated with significantly improved quality care bundle adherence.

Clinical Outcomes of Patients Treated for Candida auris Infections in a Multisite Health System, Illinois, USA.

Candida auris is an emerging fungal pathogen that is typically resistant to fluconazole and is known to cause healthcare-associated outbreaks. We retrospectively reviewed 28 patients who had >1 positive culture for C. auris within a multisite health system in Illinois, USA, during May 2018-April 2019. Twelve of these patients were treated as inpatients for C. auris infections; 10 (83%) met criteria for clinical success, defined as absence of all-cause mortality, C. auris recurrence, and infection-related readmission at 30 days from the first positive culture. The other 2 patients (17%) died within 30 days. Most patients (92%) were empirically treated with micafungin. Four (14%) of 28 total isolates were resistant to fluconazole, 1 (3.6%) was resistant to amphotericin B, and 1 (3.6%) was resistant to echinocandins. Our findings describe low rates of antifungal resistance and favorable clinical outcomes for most C. auris patients.

Efficacy of combination therapy versus monotherapy in the treatment of Stenotrophomonas maltophilia pneumonia.

BACKGROUND: Stenotrophomonas maltophilia is intrinsically resistant to several antibiotics, making it potentially challenging to treat. Studies have demonstrated treatment failures and resistance development with monotherapy (MT); however, clinical data are limited with combination therapy (CT). OBJECTIVES: To compare clinical outcomes with CT versus MT for S. maltophilia pneumonia. METHODS: This was a retrospective cohort study of patients admitted between November 2011 and October 2017 with S. maltophilia pneumonia who received at least 48 h of effective therapy. The primary outcome was clinical response after 7 days of effective therapy with CT versus MT. Secondary outcomes included development of a non-susceptible isolate, 30 day microbiological cure, infection recurrence, infection-related mortality and all-cause mortality. The Wilcoxon rank sum test, the Pearson χ2 test and Fisher's exact test were utilized for univariate analyses. A multivariable logistic regression model was used to assess clinical response while adjusting for confounding variables. RESULTS: Of 252 patients with S. maltophilia pneumonia included, 38 received CT and 214 received MT. There was no difference in 7 day clinical response with CT versus MT (47.4% versus 39.7%, P = 0.38), even after controlling for immune status, APACHE II score and polymicrobial pneumonia (adjusted OR 1.51, 95% CI 0.63-3.65). Thirty day microbiological cure (P = 0.44), recurrence (P = 0.53), infection-related mortality (P = 0.19) and isolation of a non-susceptible isolate during or after therapy (P = 1.00 each) were also similar between both groups; however, 30 day all-cause mortality was greater with CT (P = 0.03). CONCLUSIONS: CT had similar rates of clinical efficacy and resistance development compared with MT for S. maltophilia pneumonia.

Multiple-Dose Oritavancin Evaluation in a Retrospective Cohort of Patients with Complicated Infections.

OBJECTIVE: Oritavancin is a lipoglycopeptide antibiotic approved for use in acute bacterial skin and skin structure infections as a single 1200-mg parenteral dose. Because of oritavancin's long half-life and broad gram-positive activity, interest in its use for other infections is high. METHODS: This study is a retrospective cohort evaluation of patients receiving oritavancin at a single academic medical center. All patients receiving more than one dose of oritavancin were included. Patients were excluded if therapy was interrupted by more than 14 days. Efficacy, defined a priori as clinical success, improvement, or failure, and adverse drug effect outcomes were collected. RESULTS: Seventeen patients received multiple oritavancin doses (range 2-18 doses) for the treatment of complicated infections including osteomyelitis, surgical site infection, intravascular infections, and pneumonia. All patients achieved clinical success or improvement with oritavancin. Four patients (24%) had an adverse event requiring oritavancin discontinuation that reversed rapidly. CONCLUSIONS: Off-label oritavancin use may be a safe and effective alternative to daily antibiotic infusions to treat complicated infectious disease processes. This study is limited by small sample size and retrospective design, but it provides information on using oritavancin in these complex gram-positive infections.

Top 1% of Inpatients Administered Antimicrobial Agents Comprising 50% of Expenditures: A Descriptive Study and Opportunities for Stewardship Intervention.

OBJECTIVE To characterize the top 1% of inpatients who contributed to the 6-month antimicrobial budget in a tertiary, academic medical center and identify cost-effective intervention opportunities targeting high-cost antimicrobial utilization. DESIGN Retrospective cohort study. PATIENTS Top 1% of the antimicrobial budget from July 1 through December 31, 2014. METHODS Patients were identified through a pharmacy billing database. Baseline characteristics were collected through a retrospective medical chart review. Patients were presented to the antimicrobial stewardship team to determine appropriate utilization of high-cost antimicrobials and potential intervention opportunities. Appropriate use was defined as antimicrobial therapy that was effective, safe, and most cost-effective compared with alternative agents. RESULTS A total of 10,460 patients received antimicrobials in 6 months; 106 patients accounted for $889,543 (47.2%) of the antimicrobial budget with an antimicrobial cost per day of $219±$192 and antimicrobial cost per admission of $4,733±$7,614. Most patients were immunocompromised (75%) and were followed by the infectious disease consult service (80%). The most commonly prescribed antimicrobials for treatment were daptomycin, micafungin, liposomal amphotericin B, and meropenem. Posaconazole and valganciclovir accounted for most of the prophylactic therapy. Cost-effective opportunities (n=71) were present in 57 (54%) of 106 patients, which included dose optimization, de-escalation, dosage form conversion, and improvement in transitions of care. CONCLUSION Antimicrobial stewardship oversight is important in implementing cost-effective strategies, especially in complex and immunocompromised patients who require the use of high-cost antimicrobials. Infect Control Hosp Epidemiol 2017;38:259-265.