Counting the Cost of Daptomycin Versus Vancomycin in Hospitalized Patients: A Cost Minimization Analysis.

Daptomycin use for gram-positive infections has increased. This cost minimization analysis aimed to determine cost and/or time savings of daptomycin over vancomycin. The estimated hospital cost savings was US$166.41 per patient, and pharmacist time saved of almost 20 minutes per patient. Daptomycin has the potential to save both time and money.

Methicillin-Resistant Staphylococcus aureus Bacteremia Treated With Vancomycin Calculated by Area-Under-the-Curve in Patients With Elevated Vancomycin Minimum Inhibitory Concentrations.

Purpose: Vancomycin is recommended as first-line treatment of methicillin-resistant Staphylococcus aureus (MRSA) bacteremia, dosed by area-under-the-curve (AUC) with an assumed minimum inhibitory concentration (MIC) of 1 mcg/mL via broth microdilution. The purpose of this study was to compare effectiveness of AUC-based and trough-based dosing in MRSA bacteremia with an MIC > 1 mcg/mL via Etest. Methods: This was a retrospective, observational cohort that compared vancomycin dosed by AUC or trough between January 1, 2017 and September 1, 2022. The primary outcome was a composite of treatment failure defined as peristent bacteremia ≥ 7 days, inpatient mortality within 90 days, or microbiologic relapse or readmission within 30 days. Secondary outcomes compared nephrotoxicity, hospital and ICU length of stay, MIC differences, and difference in exposure measured by AUC. Results: Twenty-four patients in each group met inclusion criteria. For the primary outcome, there was no statistical difference in treatment failure between trough and AUC groups, respectively [10 (41.7%) vs 10 (41.7%), P = 1.000]. There was no statistical difference in secondary outcomes, with incidence of nephrotoxicity [3 (12.5%) trough vs 2 (8.33%) AUC, P = 1.000] and median AUC exposure over treatment course [502.9 mcg.h/mL (454.1-599.9) vs 474 mcg.h/mL (435.3-533), P = .312] similar between groups. Conclusion: There was no statistically significant difference in treatment failure for vancomycin by AUC or trough with an Etest MIC > 1 mcg/mL. Overall exposure to vancomycin and incidence of nephrotoxicty were numerically higher in the trough group, suggesting that dosing by AUC may limit exposure without impact on treatment failure.

Future governance of the RCVS: democracy or oligarchy?

Bruce Vivash Jones argues that the recent announcement from the RCVS that it is moving to 'scrap elections to council' raises many questions and concerns.

The prevalence of gram-negative bacteria with difficult-to-treat resistance and utilization of novel ß-lactam antibiotics in the southeastern United States.

Objective: To evaluate temporal trends in the prevalence of gram-negative bacteria (GNB) with difficult-to-treat resistance (DTR) in the southeastern United States. Secondary objective was to examine the use of novel ß-lactams for GNB with DTR by both antimicrobial use (AU) and a novel metric of adjusted AU by microbiological burden (am-AU). Design: Retrospective, multicenter, cohort. Setting: Ten hospitals in the southeastern United States. Methods: GNB with DTR including Enterobacterales, Pseudomonas aeruginosa, and Acinetobacter spp. from 2015 to 2020 were tracked at each institution. Cumulative AU of novel ß-lactams including ceftolozane/tazobactam, ceftazidime/avibactam, meropenem/vaborbactam, imipenem/cilastatin/relebactam, and cefiderocol in days of therapy (DOT) per 1,000 patient-days was calculated. Linear regression was utilized to examine temporal trends in the prevalence of GNB with DTR and cumulative AU of novel ß-lactams. Results: The overall prevalence of GNB with DTR was 0.85% (1,223/143,638) with numerical increase from 0.77% to 1.00% between 2015 and 2020 (P = .06). There was a statistically significant increase in DTR Enterobacterales (0.11% to 0.28%, P = .023) and DTR Acinetobacter spp. (4.2% to 18.8%, P = .002). Cumulative AU of novel ß-lactams was 1.91 ± 1.95 DOT per 1,000 patient-days. When comparing cumulative mean AU and am-AU, there was an increase from 1.91 to 2.36 DOT/1,000 patient-days, with more than half of the hospitals shifting in ranking after adjustment for microbiological burden. Conclusions: The overall prevalence of GNB with DTR and the use of novel ß-lactams remain low. However, the uptrend in the use of novel ß-lactams after adjusting for microbiological burden suggests a higher utilization relative to the prevalence of GNB with DTR.

Dalbavancin Sequential Therapy for Gram-Positive Bloodstream Infection: A Multicenter Observational Study.

INTRODUCTION: Long-acting lipoglycopeptides such as dalbavancin may have utility in patients with Gram-positive bloodstream infections (BSI), particularly in those with barriers to discharge or who require prolonged parenteral antibiotic courses. A retrospective cohort study was performed to provide further multicenter real-world evidence on dalbavancin use as a sequential therapy for Gram-positive BSI. METHODS: One hundred fifteen patients received dalbavancin with Gram-positive BSI, defined as any positive blood culture or diagnosed with infective endocarditis, from 13 centers geographically spread across the United States between July 2015 and July 2021. RESULTS: Patients had a mean (SD) age of 48.5 (17.5) years, the majority were male (54%), with many who injected drugs (40%). The most common infection sources (non-exclusive) were primary BSI (89%), skin and soft tissue infection (SSTI) (25%), infective endocarditis (19%), and bone and joint infection (17%). Staphylococcus aureus accounted for 72% of index cultures, coagulase-negative Staphylococcus accounted for 18%, and Streptococcus species in 16%. Dalbavancin started a median (Q1-Q3) of 10 (6-19) days after index culture collection. The most common regimen administered was dalbavancin 1500 mg as one dose for 50% of cases. The primary outcome of composite clinical failure occurred at 12.2%, with 90-day mortality at 7.0% and 90-day BSI recurrence at 3.5%. CONCLUSIONS: Dalbavancin may serve as a useful tool in facilitating hospital discharge in patients with Gram-positive BSI. Randomized controlled trials are anticipated to validate dalbavancin as a surrogate to current treatment standards.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2022.

Keeping abreast of the antimicrobial stewardship-related articles published each year is challenging. The Southeastern Research Group Endeavor identified antimicrobial stewardship-related, peer-reviewed literature that detailed an actionable intervention during 2022. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight actionable interventions used by antimicrobial stewardship programs to capture potentially effective strategies for local implementation.

Eravacycline, the first four years: health outcomes and tolerability data for 19 hospitals in 5 U.S. regions from 2018 to 2022.

IMPORTANCE: The rise of multidrug-resistant (MDR) pathogens, especially MDR Gram-negatives, poses a significant challenge to clinicians and public health. These resilient bacteria have rendered many traditional antibiotics ineffective, underscoring the urgency for innovative therapeutic solutions. Eravacycline, a broad-spectrum fluorocycline tetracycline antibiotic approved by the FDA in 2018, emerges as a promising candidate, exhibiting potential against a diverse array of MDR bacteria, including Gram-negative, Gram-positive, anaerobic strains, and Mycobacterium. However, comprehensive data on its real-world application remain scarce. This retrospective cohort study, one of the largest of its kind, delves into the utilization of eravacycline across various infectious conditions in the USA during its initial 4 years post-FDA approval. Through assessing clinical, microbiological, and tolerability outcomes, the research offers pivotal insights into eravacycline's efficacy in addressing the pressing global challenge of MDR bacterial infections.

Injuries and Factors Associated with Injuries Among U.S. Army Band Musicians.

The Department of Defense is the largest employer of full-time musicians. In the U.S. military, many musicians experience unique occupational exposures such as extended periods of standing, sitting, and marching for rehearsals and performances, static and non-neutral postures, and a variety of repetitive motions while playing instruments. These exposures are in addition to physical training and fitness standards required of U.S. Army soldiers. METHODS: An electronic survey was administered to active-duty U.S. Army Band musicians. The survey collected demographics, personal characteristics, Army Physical Fitness Test performance, occupational demands, health behaviors, and injuries from October 2017 to December 2018. Survey responses were combined with medical and physical fitness performance records. Descriptive statistics were reported and factors associated with injuries were investigated. RESULTS: There were 465 Army Band members in this population, with approximately half (49%) completing the survey. Most survey respondents (81%) reported an injury in the past year, which they predominantly attributed to overuse (54%). Leading reported activities resulting in injury included running for physical training (21%), repetitive movements while playing an instrument (11%), and standing while playing (11%). A majority of survey respondents (60%) also had a medical encounter for an injury. Factors significantly associated with injury among men were lower aerobic fitness and higher body fat percentage; additional unadjusted factors associated with injury among all Army Band soldiers included female sex, older age, and longer periods of marching and standing while playing. CONCLUSIONS: Injury prevention initiatives for Army Band musicians should focus on the reduction of overuse and repetitive motion injuries. Suggested prevention strategies include balanced physical training, ergonomic adjustments, rehearsal breaks, and leadership support for injury prevention efforts.

Demographic, psychosocial, and physical fitness predictors of successful graduation from U.S. Army Ranger School.

U.S. Army Ranger School is an arduous 64-day leadership training course designed to simulate the stressors of combat. Although physical fitness has been shown to be an important predictor of successful graduation for Ranger School, psychosocial characteristics like self-efficacy and grit have not been examined. The purpose of this study is to identify personal, psychosocial, and fitness characteristics associated with successful completion of Ranger School. This study was a prospective cohort examining the association of baseline characteristics of Ranger School candidates with a primary outcome of graduation success. Multiple logistic regression was performed to determine the contribution of demographics, psychosocial, fitness and training characteristics to graduation success. Out of 958 eligible Ranger Candidates, this study obtained graduation status for 670 students, 270 (40%) of which graduated. Soldiers who graduated were younger, more likely to come from units with a higher proportion of previous Ranger School graduates, had higher self-efficacy and faster 2-mile run times. The results from this study suggest that Ranger students should arrive in optimal physical conditioning. Furthermore, training programs that optimize student self-efficacy and units with a high proportion of successful Ranger graduates may confer advantage for this challenging leadership course.

Physical and behavioral characteristics of soldiers acquiring recommended amounts of sleep per night.

OBJECTIVES: Only one-third of U.S. Army Soldiers meet the recommended sleep guideline of 7 or more hours per night. Soldiers meeting the recommended sleep guideline are more likely to perform better on cognitive and physical tasks. The purpose of this analysis was to compare the physical and behavioral characteristics of Soldiers who met and did not meet the sleep recommendation guideline and determine associations between physical and behavioral characteristics and the acquisition of recommended amounts of sleep per night. METHODS: A survey was administered to U.S. Army Soldiers. Adjusted odds ratios and corresponding 95% confidence intervals were calculated to determine associations between achieving the recommended number of hours of sleep per night and age, physical characteristics, health behaviors, physical training, and physical performance. RESULTS: A survey was completed by 4229 men and 969 women. Male Soldiers who met the recommended sleep requirement had lower estimated body fat [20.3 ± 4.2% vs. 21.1 ± 4.4%], were less likely to use tobacco [11.5% vs. 16.2%] and exercised more [259 ± 226 vs. 244 ± 224 min/wk] compared with those who did not obtain 7 hours of sleep per night. Female Soldiers who met the recommended sleep requirement had lower estimated body fat [31.4 ± 4% vs. 32.1 ± 4.6%] and exercised more [258 ± 206 vs. 241 ± 216 min/wk] compared with those who did not obtain 7 hours of sleep per night. CONCLUSION: Soldiers who choose to adopt healthy lifestyle characteristics may be more likely to meet the recommended sleep duration guideline.

Penicillin-allergy delabelling resources for clinicians practicing in resource-limited settings: a full educational resource review of the grey literature.

Background: The clinical and financial consequences associated with a penicillin-allergy label are increasingly evident and have garnered support from international organizations to prioritize penicillin-allergy delabelling programmes. Most settings lack access to resources including drug allergy specialists and rely on general practitioners (GPs) and pharmacists. Objectives: The aim of this scoping review was to identify and describe freely available penicillin-allergy delabelling materials to guide clinicians practising in resource-limited settings with initiative application. Methods: This scoping review searched two grey literature databases, six targeted websites and consulted content experts to identify freely available materials in the English language that provided evidence-based and actionable penicillin-allergy delabelling strategies. Study investigators ranked and voted on which screened resources should be included in the final review. Characteristics of resources were evaluated and compared. Results: Out of 1191 total citations, 6 open-access resources were included. Penicillin-allergy toolkits featuring various delabelling strategies were identified in four resources. The toolkits supported a broad range of downloadable and adaptable materials, predominantly targeted towards GPs. Patient educational materials were also provided. Another resource highlighted a point-of-care penicillin-allergy risk assessment calculator via a free mobile app that quickly and accurately identified low-risk penicillin-allergic patients. The final resource, a supplemental instructional video, presented impactful and standardized delabelling strategies that clinicians can adopt into daily practices. Conclusions: Limited penicillin-allergy delabelling materials are available in the grey literature but existing resources provide broad and diverse opportunities. Additional support from health protection agencies is critical to augment ongoing delabelling efforts.

Assessing Community-Based Public Health Plans: An Example From US Army Injury Prevention.

CONTEXT: The US Army requires community health coalitions to develop action plans for their top public health priorities. OBJECTIVE: To date, the US Army has not implemented a standardized review process for community action plans. DESIGN: This project used the Plan Quality Index (PQI), an evidence-based, standardized tool, to evaluate injury prevention action plans created by injury prevention teams (IPTs). SETTING: 17 Army installations. PARTICIPANTS: 17 IPT leads; 5 Health Promotion Program Officers. INTERVENTION: Implementation of the PQI to evaluate the strength of injury prevention action plans and make recommendations for quality improvement to drive reductions in injuries at 17 Army installations. MAIN OUTCOME MEASURE: PQI total scores for high- (≥50 points on the PQI) and low-ranking plans (<50 points on the PQI) were assessed for differences using t tests of the mean PQI score. Chi-square tests were employed to identify differences in meeting criteria between high- and low-scoring plans. RESULTS: PQI total scores ranged from 9 to 78 points out of 80. The weakest planning elements among all plans were lack of use of SMART objectives (18%), lack of identification of responsible parties (18%), absent evaluation plan (24%), and lack of timelines (35%). The mean score for the high-ranking plans (64.6 ± 9.5) was significantly higher than the mean score for the low-ranking plans (26.2 ± 12.7) ( P < .001). Mean scores for clarity, effectiveness, and quality were all significantly higher for the high-ranking plans than for the low-ranking plans ( P = .014, P = .002, and P < .001, respectively). CONCLUSIONS: The PQI tool provides a framework for objective, standardized, and evidence-based feedback and recommendations for improving community health plans. The project identified examples of high-quality action plans and provided actionable recommendations for plan improvement to facilitate sustainability of initiatives addressing injuries, which have long posed a threat to military health and readiness.

Evaluation of Dalbavancin in Vancomycin Allergic Patients: A Case Series.

PURPOSE: There is a paucity of data regarding dalbavancin use in patients with a vancomycin allergy because of potential cross-reactivity between the 2 glycopeptide antibiotics. METHODS: A retrospective medical record review was performed between February 2016 and February 2021 in patients with a listed vancomycin allergy who received dalbavancin as an outpatient infusion and had a listed vancomycin allergy in the electronic health record. FINDINGS: There were 559 unique patients during the study period who received dalbavancin as an outpatient infusion, 10 of whom had a documented vancomycin allergy in the electronic health record. Four of the 10 patients had a history of a type I IgE-mediated reaction to vancomycin, 1 patient reported delayed rash, 2 patients reported a vancomycin infusion reaction, 2 patients reported acute kidney injury, and 1 patient reported intolerance with general malaise. All 10 patients received at least 1 dose of dalbavancin with no reported adverse events. IMPLICATIONS: This case series displays that all patients who received dalbavancin tolerated the infusion well with no adverse events reported. Dalbavancin may be a viable option for patients with a listed vancomycin allergy.

A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications for Hospitalized Patients in 2021.

Keeping abreast of the antimicrobial stewardship-related articles published each year is challenging. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship-related, peer-reviewed literature that detailed an "actionable" intervention among hospitalized populations during 2021. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight "actionable" interventions used by antimicrobial stewardship programs in hospitalized populations to capture potentially effective strategies for local implementation.

Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders.

INTRODUCTION: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. METHODS: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services. RESULTS: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown. CONCLUSION: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Clinical Outcomes of Eravacycline in Patients Treated Predominately for Carbapenem-Resistant Acinetobacter baumannii.

Forty-six patients were treated with eravacycline (ERV) for Acinetobacter baumannii infections, where 69.5% of isolates were carbapenem resistant (CRAB). Infections were primarily pulmonary (58.3%), and most patients received combination therapy (84.4%). The median (IQR) ERV duration was 6.9 days (5.1 to 11.1). Thirty-day mortality was 23.9% in the cohort and 21.9% in CRAB patients. One patient experienced an ERV-possible adverse event. IMPORTANCE Acinetobacter baumannii, particularly when carbapenem resistant (CRAB), is one of the most challenging pathogens in the health care setting. This is complicated by the fact that there is no consensus guideline regarding management of A. baumannii infections. However, the recent Infectious Diseases Society of America guidelines for treatment of resistant Gram-negative infections provided expert recommendations for CRAB management. The panel suggest using minocycline among tetracycline derivatives rather than eravacycline (ERV) until sufficient clinical data are available. Therefore, we present the largest multicenter real-world cohort in patients treated with ERV for A. baumannii, where the majority of isolates were CRAB (69.5%). Our analysis demonstrate that patients treated with ERV-based regimens achieved a 30-day mortality of 23.9% and had a low incidence of ERV-possible adverse events (2.1%). This study is important as it fills the gap in the literature regarding the use of a novel tetracycline (i.e., ERV) in the treatment of this challenging health care infection.