Influence of Minimum Inhibitory Concentration in Clinical Outcomes of Enterococcus faecium Bacteremia Treated With Daptomycin: Is it Time to Change the Breakpoint?

BACKGROUND: Daptomycin has become a front-line antibiotic for multidrug-resistant Enterococcus faecium bloodstream infections (BSIs). We previously showed that E. faecium strains with daptomycin minimum inhibitory concentrations (MICs) in the higher end of susceptibility frequently harbor mutations associated with daptomycin resistance. We postulate that patients with E. faecium BSIs exhibiting daptomycin MICs of 3-4 µg/mL treated with daptomycin are more likely to have worse clinical outcomes than those exhibiting daptomycin MICs ≤2 µg/mL. METHODS: We conducted a multicenter retrospective cohort study that included adult patients with E. faecium BSI for whom initial isolates, follow-up blood culture data, and daptomycin administration data were available. A central laboratory performed standardized daptomycin MIC testing for all isolates. The primary outcome was microbiologic failure, defined as clearance of bacteremia ≥4 days after the index blood culture. The secondary outcome was all-cause in-hospital mortality. RESULTS: A total of 62 patients were included. Thirty-one patients were infected with isolates that exhibited daptomycin MICs of 3-4 µg/mL. Overall, 34 patients had microbiologic failure and 25 died during hospitalization. In a multivariate logistic regression model, daptomycin MICs of 3-4 µg/mL (odds ratio [OR], 4.7 [1.37-16.12]; P = .014) and immunosuppression (OR, 5.32 [1.20-23.54]; P = .028) were significantly associated with microbiologic failure. Initial daptomycin dose of ≥8 mg/kg was not significantly associated with evaluated outcomes. CONCLUSIONS: Daptomycin MICs of 3-4 µg/mL in the initial E. faecium blood isolate predicted microbiological failure of daptomycin therapy, suggesting that modification in the daptomycin breakpoint for enterococci should be considered.

Effect of different frequencies of creatine supplementation on muscle size and strength in young adults.

The purpose was to determine if creatine supplementation, consumed immediately before and immediately after exercise, with different dosing frequency (i.e., 2 or 3 d wk) could enhance the gains in muscle size and strength from resistance training (RT) in young adults. A group of 38 physically active, nonresistance trained university students (21-28 years) was randomly allocated to 1 of 4 groups: CR2 (0.15 g·kg creatine during 2 d wk of RT; 3 sets of 10 repetitions; n = 11, 6 men, 5 women), CR3 (0.10 g·kg creatine during 3 d wk of RT; 2 sets of 10 repetitions; n = 11, 6 men, 5 women;), PLA2 (placebo during 2 d wk of RT; n = 8, 5 men, 3 women), and PLA3 (placebo during 3 d wk of RT; n = 8, 4 men, 4 women) for 6 weeks. Before and after training, measurements were taken for muscle thickness of the elbow and knee flexor and extensor muscle groups (ultrasound), 1-repetition maximumleg press and chest press strength, and kidney function (urinary microalbumin). Repeated-measures analysis of variance showed that strength and muscle thickness increased in all groups with training (p < 0.05). The CR2 (0.6 ± 0.9 cm or 20%; p < 0.05) and CR3 groups (0.4 ± 0.6 cm or 16.4%; p < 0.05) experienced greater change in muscle thickness of the elbow flexors compared to the PLA2 (0.05 ± 0.5 cm or 2.3%) and PLA3 groups (0.13 ± 0.7 cm or 6.3%). Men supplementing with creatine experienced a greater increase in leg press strength (77.3 ± 51.2 kg or 62%) compared to women on creatine (21.3 ± 10 kg or 34%, p < 0.05). We conclude that creatine supplementation during RT has a small beneficial effect on regional muscle thickness in young adults but that giving the creatine over 3 d wk did not differ from giving the same dose over 2 d wk.

An Analysis of Adherence to Vaccination Recommendations in a Thoracic Organ Transplant Cohort.

(1) Background: Vaccination of solid organ transplant (SOT) candidates and recipients is vital to decrease infection-related morbidity and mortality. Here we describe our heart and lung transplant programs' rates of completion of hepatitis B and pneumococcal vaccinations and identify potential opportunities for improvement. (2) Methods: This is a single-center retrospective study that included all heart and lung transplant recipients between 1 July 2013 and 31 July 2018. We assessed demographics, causes of organ failure, pretransplant hepatitis B immune status, and completion rates for hepatitis B vaccine series, pneumococcal conjugate vaccine (PCV13), and pneumococcal polysaccharide vaccine (PPSV23). (3) Results: A total of 41 patients were included in the heart transplant cohort. Twelve (29.3%) had baseline hepatitis B immunity. Only 8/29 (27.6%) completed the entire 3-dose hepatitis B vaccination series pretransplant. Pretransplant PCV13 and PPSV23 vaccination rates were 58.5% (24/41) and 48.8% (20/41), respectively; no additional patients received PCV13 or PPSV23 post-transplant. In the heart transplant cohort, a majority (82.9%) of patients were evaluated by the Transplant Infectious Diseases consultative service (TxID) pretransplant, and this had a statistically significant association with increased pneumococcal vaccination rates (p = 0.0017, PCV13 and p = 0.0103, PPSV23). In total, 55 patients were included in the lung transplant cohort. Five (9.1%) had baseline hepatitis B immunity; 33/50 (66.0%) completed the hepatitis B vaccine series in the pretransplant setting. Pretransplant PCV13 and PPSV23 vaccination rate was 40.0% (22/55) and 69.1% (38/55), respectively. There was only a 47.3% and 72.3% completion rate overall in the post-transplant setting. (4) Conclusions: There continues to be a need for a comprehensive and coordinated effort to increase vaccine adherence for all SOT candidates in the pretransplant setting.

Septic arthritis due to oral streptococci following intra-articular injection: A case series.

Oral streptococcal species are a rare cause of septic arthritis. We describe 4 cases of septic arthritis due to oral streptococcal species following joint injection. The routine use of face masks during joint injection may prevent this rare but serious complication.

Preparedness planning and care of patients under investigation for or with Ebola virus disease: A survey of physicians in North America.

The West African Ebola virus disease (EVD) epidemic of 2014-2015 required North American hospitals to undertake comprehensive planning and training for the potential need to care for patients with EVD. Here we describe physician contributions to EVD preparedness planning and the care of persons under investigation for or patients with EVD.

Multidrug-Resistant Bacterial Donor-Derived Infections in Solid Organ Transplantation.

Although rare, donor-derived infections (DDIs) caused by multidrug-resistant (MDR) bacteria can have devastating consequences for organ transplant recipients. Recognition of MDR bacterial DDIs can be challenging, as MDR bacteria are prevalent in most hospitals and distinguishing their transmission through transplantation from other, more typical routes of acquisition are difficult. New technologies such as whole genome sequencing have recently proven to be a powerful advance in the investigation of MDR bacterial DDIs. Once recognized, the optimal treatment of MDR bacterial DDIs is not clear. Herein, we review the clinical manifestations, outcomes, and management of MDR bacterial DDIs, and identify areas of uncertainty toward which the transplant community should direct further research efforts.

Hepatitis B in healthcare workers: Transmission events and guidance for management.

Hepatitis B virus (HBV) is the most efficiently transmissible of the bloodborne viruses that are important in healthcare settings. Healthcare workers (HCWs) are at risk for exposure to HBV from infected patients and, if infected, are similarly at risk of transmitting HBV to patients. Published cases of HBV transmission from HCW to patient are relatively rare, having decreased in frequency following the introduction of standard (universal) precautions, adoption of enhanced percutaneous injury precautions such as double-gloving in surgery, and routine HBV vaccination of HCWs. Here we review published cases of HCW-to-patient transmission of HBV, details of which have helped to guide the creation of formal guidelines for the management of HBV-infected HCWs. We also compare the published guidelines for the management of HBV-infected HCWs from various governing bodies, focusing on their differences with regard to vaccination requirements, viral load limits, frequency of monitoring, and restrictions on practice. Importantly, while there are differences among the recommendations from governing bodies, no guidelines uniformly restrict HBV-infected HCWs from performing invasive or exposure-prone procedures.

The limits of serial surveillance cultures in predicting clearance of colonization with carbapenemase-producing Enterobacteriaceae.

An accepted practice for patients colonized with multidrug-resistant organisms is to discontinue contact precautions following 3 consecutive negative surveillance cultures. Our experience with surveillance cultures to detect persistent carbapenemase-producing Enterobacteriaceae (CPE) colonization suggests that extrapolation of this practice to CPE-colonized patients may not be appropriate.

Control of simultaneous outbreaks of carbapenemase-producing enterobacteriaceae and extensively drug-resistant Acinetobacter baumannii infection in an intensive care unit using interventions promoted in the Centers for Disease Control and Prevention 2012 carbapenemase-resistant Enterobacteriaceae Toolkit.

OBJECTIVE: We describe the efficacy of enhanced infection control measures, including those recommended in the Centers for Disease Control and Prevention's 2012 carbapenem-resistant Enterobacteriaceae (CRE) toolkit, to control concurrent outbreaks of carbapenemase-producing Enterobacteriaceae (CPE) and extensively drug-resistant Acinetobacter baumannii (XDR-AB). DESIGN: Before-after intervention study. SETTING: Fifteen-bed surgical trauma intensive care unit (ICU). METHODS: We investigated the impact of enhanced infection control measures in response to clusters of CPE and XDR-AB infections in an ICU from April 2009 to March 2010. Polymerase chain reaction was used to detect the presence of blaKPC and resistance plasmids in CRE. Pulsed-field gel electrophoresis was performed to assess XDR-AB clonality. Enhanced infection-control measures were implemented in response to ongoing transmission of CPE and a new outbreak of XDR-AB. Efficacy was evaluated by comparing the incidence rate (IR) of CPE and XDR-AB before and after the implementation of these measures. RESULTS: The IR of CPE for the 12 months before the implementation of enhanced measures was 7.77 cases per 1,000 patient-days, whereas the IR of XDR-AB for the 3 months before implementation was 6.79 cases per 1,000 patient-days. All examined CPE shared endemic blaKPC resistance plasmids, and 6 of the 7 XDR-AB isolates were clonal. Following institution of enhanced infection control measures, the CPE IR decreased to 1.22 cases per 1,000 patient-days (P = .001), and no more cases of XDR-AB were identified. CONCLUSIONS: Use of infection control measures described in the Centers for Disease Control and Prevention's 2012 CRE toolkit was associated with a reduction in the IR of CPE and an interruption in XDR-AB transmission.

Admission surveillance for carbapenamase-producing Enterobacteriaceae at a long-term acute care hospital.

Carbapenemase-producing Enterobacteriaceae (CPE) are of increasing prevalence worldwide, and long-term acute care hospitals (LTACHs) have been implicated in several outbreaks in the United States. This prospective study of routine screening for CPE on admission to a LTACH demonstrates a high prevalence of CPE colonization in central Virginia.