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.

A pan-influenza antibody inhibiting neuraminidase via receptor mimicry

Rapidly evolving influenza A viruses (IAVs) and influenza B viruses (IBVs) are major causes of recurrent lower respiratory tract infections. Current influenza vaccines elicit antibodies predominantly to the highly variable head region of haemagglutinin and their effectiveness is limited by viral drift¹ and suboptimal immune responses². Here we describe a neuraminidase-targeting monoclonal antibody, FNI9, that potently inhibits the enzymatic activity of all group 1 and group 2 IAVs, as well as Victoria/2/87-like, Yamagata/16/88-like and ancestral IBVs. FNI9 broadly neutralizes seasonal IAVs and IBVs, including the immune-evading H3N2 strains bearing an N-glycan at position 245, and shows synergistic activity when combined with anti-haemagglutinin stem-directed antibodies. Structural analysis reveals that D107 in the FNI9 heavy chain complementarity-determinant region 3 mimics the interaction of the sialic acid carboxyl group with the three highly conserved arginine residues (R118, R292 and R371) of the neuraminidase catalytic site. FNI9 demonstrates potent prophylactic activity against lethal IAV and IBV infections in mice. The unprecedented breadth and potency of the FNI9 monoclonal antibody supports its development for the prevention of influenza illness by seasonal and pandemic viruses.

The Queensland Twin Adolescent Brain Project, a longitudinal study of adolescent brain development

We describe the Queensland Twin Adolescent Brain (QTAB) dataset and provide a detailed methodology and technical validation to facilitate data usage. The QTAB dataset comprises multimodal neuroimaging, as well as cognitive and mental health data collected in adolescent twins over two sessions (session 1: N = 422, age 9-14 years; session 2: N = 304, 10-16 years). The MRI protocol consisted of T1-weighted (MP2RAGE), T2-weighted, FLAIR, high-resolution TSE, SWI, resting-state fMRI, DWI, and ASL scans. Two fMRI tasks were added in session 2: an emotional conflict task and a passive movie-watching task. Outside of the scanner, we assessed cognitive function using standardised tests. We also obtained self-reports of symptoms for anxiety and depression, perceived stress, sleepiness, pubertal development measures, and risk and protective factors. We additionally collected several biological samples for genomic and metagenomic analysis. The QTAB project was established to promote health-related research in adolescence.

Interactions between the lipidome and genetic and environmental factors in autism

Autism omics research has historically been reductionist and diagnosis centric, with little attention paid to common co-occurring conditions (for example, sleep and feeding disorders) and the complex interplay between molecular profiles and neurodevelopment, genetics, environmental factors and health. Here we explored the plasma lipidome (783 lipid species) in 765 children (485 diagnosed with autism spectrum disorder (ASD)) within the Australian Autism Biobank. We identified lipids associated with ASD diagnosis (n = 8), sleep disturbances (n = 20) and cognitive function (n = 8) and found that long-chain polyunsaturated fatty acids may causally contribute to sleep disturbances mediated by the FADS gene cluster. We explored the interplay of environmental factors with neurodevelopment and the lipidome, finding that sleep disturbances and unhealthy diet have a convergent lipidome profile (with potential mediation by the microbiome) that is also independently associated with poorer adaptive function. In contrast, ASD lipidome differences were accounted for by dietary differences and sleep disturbances. We identified a large chr19p13.2 copy number variant genetic deletion spanning the LDLR gene and two high-confidence ASD genes (ELAVL3 and SMARCA4) in one child with an ASD diagnosis and widespread low-density lipoprotein-related lipidome derangements. Lipidomics captures the complexity of neurodevelopment, as well as the biological effects of conditions that commonly affect quality of life among autistic people.

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.

Patients experiences of using a publicly avaliable mobile health application for self-care of heart failure in a real-world setting

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): University of Kentucky disseration award

Background

Publicly available patient-focused mobile health applications (mHealth apps) are being increasingly integrated into routine heart failure (HF)-related self-care. However, there is a dearth of research on patients’ experiences using mHealth apps for self-care in real-world settings. The purpose of this study was to explore patients’ experiences using a publicly available mHealth app, OnTrack to Health, for HF self-care in a real-world setting.

Method

Patient satisfaction, measured with a 5-point Likert scale and an open-ended survey were used to gather data from 23 patients with HF who were provided the OnTrack to Health app as a part of routine HF management. A content analysis of patients’ responses was conducted with qualitative software, Atlas. ti version 8.

Results

Patients (median age = 64.0 [57.0, 70.5] years, 73.9% (n = 17) male) used OnTrack to Health for a median duration of 164.0 [ 51.2, 639.9] days before the survey. All patients reported excellent experiences related to app use and would recommend the app to other patients with HF. Four themes emerged from the responses to the open-ended questions: (1) perceived benefits (simplified self-care tasks, improved adherence to medications, enhanced communication and connection with healthcare providers, facilitated HF symptoms monitoring, improved HF knowledge, decreased hospitalization, and provided assurance of safety); (2) barriers (challenges of abandoning previous self-care strategies); (3) facilitators (perceived ease of use, availability of technical support); (4) suggested improvements (streamlining data entry, integration of apps with an electronic medical record, and personalization of app features).

Conclusion

Patients were satisfied with using mHealth apps for self-care. They perceived apps as a valuable tool for improving self-care ability and decreasing hospitalization rates. Personalization of app features and integration of mHealth apps with electronic health records are essential to sustain high-quality patient experiences related to app use for self-care.

Does perceived stress mediate the relationship between financial status, depression, and anxiety in caregivers at risk for cardiovascular disease (CVD)?

Funding Acknowledgements

Type of funding sources: Public Institution(s). Main funding source(s): National Institutes of Health National Institute of Nursing Research

Background/Introduction

Caregivers are at high risk of anxiety and depression, and caregiver mental health is linked to higher CVD risk in caregivers over their non-caregiving peers. Most research focuses on caregiver burden as a primary cause for caregiver’s emotional distress, such as anxiety and depression. Other stressors like financial burden are less emphasized, despite widespread documentation of financial burden as a key social determinant of health. We hypothesize financial status predicts anxiety and depression through perceived stress.

Purpose

To identify the relationship between financial status and caregiver anxiety and depression and determine if it is mediated by perceived stress.

Methods

We analyzed cross-sectional data from the Rural Intervention for Caregiver’s Heart Health study. Anxiety was assessed using the Brief Symptom Inventory – Anxiety subscale (range 0 -3.5) and depression was assessed by the Patient Health Questionnaire –9 (range 0 - 27). Financial status was measured with one item that asked participants to rank their financial situation by level of comfort (not enough to make ends meet, enough to make ends meet, and comfortable), and perceived stress measured with Cohen’s Perceived Stress Scale – 4. Analysis was performed separately for the two mental health outcomes using OLS regression and, to test mediation, the PROCESS macro for SPSS and the bootstrapping procedure with 5,000 samples. We included age, gender, marital status, number of people in the household, body mass index, smoking status, and caregiver burden as covariates.

Results

Of the 287 participants, average age was 54 ± 13; 76% were female, 95.8% were Caucasian, and 70.4% were married. Controlling for covariates, caregivers with not enough to make ends meet reported substantially greater depressive symptoms (b=2.22, 95% CI = 0.48 – 3.96) and marginally greater anxiety (b=0.23, 95% CI = -0.02 – 0.47) compared to caregivers who were financially comfortable. These associations were not mediated by perceived stress as hypothesized.

Conclusions

Among caregivers who are at risk for CVD, financial status was important in reporting both depression and to a lesser extent, anxiety however perceived stress does not mediate this relationship. This is interesting as perceived stress is often a target for interventions that focus on reducing depression and anxiety in this population however our analysis emphasizes the importance of financial status alone. When designing interventions to reduce the CVD risk factors of anxiety and depression, more attention should be paid to relieving financial burden.

Autism-related dietary preferences mediate autism-gut microbiome associations

There is increasing interest in the potential contribution of the gut microbiome to autism spectrum disorder (ASD). However, previous studies have been underpowered and have not been designed to address potential confounding factors in a comprehensive way. We performed a large autism stool metagenomics study (n = 247) based on participants from the Australian Autism Biobank and the Queensland Twin Adolescent Brain project. We found negligible direct associations between ASD diagnosis and the gut microbiome. Instead, our data support a model whereby ASD-related restricted interests are associated with less-diverse diet, and in turn reduced microbial taxonomic diversity and looser stool consistency. In contrast to ASD diagnosis, our dataset was well powered to detect microbiome associations with traits such as age, dietary intake, and stool consistency. Overall, microbiome differences in ASD may reflect dietary preferences that relate to diagnostic features, and we caution against claims that the microbiome has a driving role in ASD.

Linking salt preference to enjoyment of low sodium diet in patients with heart failure

Background

Preference for salty foods is linked to dietary sodium intake. Increased salt preference is a barrier to low sodium diet (LSD) adherence due to perceived poor taste. Although patients with heart failure (HF) are advised to follow a LSD, the adherence remains poor. Understanding the relationship among attitudes, subjective norms (individuals' beliefs about how much they follow the advice of respected others), and perceived control for following a LSD, salt preference, and LSD enjoyment will help in designing interventions to increase adherence in patients with HF.

Purpose

The purpose of this study was to examine whether attitudes toward following a LSD, subjective norms about LSD, and perceived behavioral control for following a LSD mediated the association between salt preference and enjoyment of a LSD in patients with HF.

Methods

In this cross-sectional study, outpatients with HF completed the Dietary Sodium Restriction Questionnaire (DSRQ) based on the Theory of Planned Behavior, and rated salt preference and enjoyment of a LSD on a scale from 0 to 10 with 10 indicating the highest salt preference and enjoyment of LSD. Parallel mediation analyses were conducted using the PROCESS macro program in SPSS with 5,000 bootstrap samples controlling for age and gender. Three subscales of the DSRQ (i.e., attitude, subjective norms, and perceived behavioral control) were used as mediators.

Results

A sample of 117 patients with HF (65% male, mean age = 61.2±14.3, range 27 to 94, 82% white) completed the study. The mean salt preference rating was 5.26 (SD=2.7), and the LSD enjoyment rating was 4.56 (SD=2.5). Salt preference was not directly associated with LSD enjoyment (direct effect = −0.0506, 95% CI: [−0.2394, 0.1381]). There was a significant indirect effect of salt preference on the enjoyment of LSD through perceived behavioral control (indirect effect = −0.1178, 95% CI: [−0.0321, 0.0446]) (Figure 1). Patients with a high salt preference were more likely to have low levels of LSD enjoyment through the mediator of having low levels of perceived behavioral control over following a LSD. Subjective norms and attitudes toward LSD were not significant mediators of the association between salt preference and LSD enjoyment.

Conclusion

High preference for salty food decreased perceived behavioral control of LSD, which reduced enjoyment of LSD in patients with HF. Salt preference and perceived behavioral control in LSD are behavioral barriers in hedonic shift in LSD enjoyment. The findings suggest that intervention to promote LSD adherence should include strategies to increase perceived behavioral control in eating LSD and decreasing salt preference.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): National Institutes of Health in the USA

Association of age and dietary sodium intake in patients with heart failure: testing mediating effects of preference for salt and enjoyment of sodium-restricted diet

Funding Acknowledgements

Type of funding sources: Other. Main funding source(s): National Institutes of Health (NIH)

Background

The poor taste foods in a low sodium diet and patients’ preferences for salty foods are known barriers to sodium restricted diet (SRD) adherence. Older adults may experience less enjoyment of SRD due to decreased sense of taste. However, little is known about how age is associated with sodium intake, preference for salt, and enjoyment of SRD in patients with heart failure (HF).

Purpose

The purpose of this study was to examine effect of age on dietary sodium intake through their preference for salt and enjoyment of SRD in patients with HF.

Methods

 In this cross-sectional study, we used baseline data from participants in a randomized controlled trial of a SRD intervention for patients with HF and their caregivers. Patients were asked to collect 24-hour urine to measure dietary sodium intake. Preference for salty food and enjoyment of SRD were assessed using a question on an 11-point numeric scale (range 0 to 10). Parallel mediation analyses were conducted using the PROCESS macro program in SPSS with 5,000 bootstrap samples.

Results

A total of 136 patients with HF (64% male, mean age = 60.3 ± 14.4, range 27 to 90, 80.1% white) had a mean 24-hr urine sodium of 4320mg (SD = 2053, range: 1553 mg – 11495 mg) with most (71%) having a 24-hr urine sodium &gt; 3000mg. The mean preference for salty food was 5.3 (SD = 2.8) on a scale from 0 to 10 with 10 indicating greater preference and enjoyment of SRD was 4.4 (SD = 2.5) on the same scale. Age was significantly associated with sodium intake in that older patients were more likely to eat less sodium (effect= -40.3236, 95% CI= [-63.7151, -16.9321]). The indirect effects of age on sodium intake through preference of salty food (effect= .7033, 95% CI = [-2.3361, 4.5357]) and enjoyment of SRD (effect = -.0271, 95% CI = [ -3.2736, 2.2213]) were not significant, indicating that these factors did not mediate the relationship between age and dietary sodium consumption. When we controlled gender, education, and ethnicity, age was also associated with sodium intake, but the two indirect effects were not significant.

Conclusion

Although most patients consumed foods high in sodium, older patients were more likely to consume foods lower in salt. However, contrary to what we expected, preference for salty foods and enjoyment of SRD did not play mediator roles in the association of age with salt consumption. The findings suggest that older adults may need different types of intervention to promote adherence than younger patients. Further research is needed to explore other factors related to SRD (e.g., efficacy of SRD or perceived control of diet behaviors) that affect sodium intake in patients with HF.

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.

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.

Low-Dose Anti-Thymocyte Globulin Preserves C-Peptide, Reduces HbA1c, and Increases Regulatory to Conventional T-Cell Ratios in New-Onset Type 1 Diabetes: Two-Year Clinical Trial Data

A three-arm, randomized, double-masked, placebo-controlled phase 2b trial performed by the Type 1 Diabetes TrialNet Study Group previously demonstrated that low-dose anti-thymocyte globulin (ATG) (2.5 mg/kg) preserved β-cell function and reduced HbA_1c for 1 year in new-onset type 1 diabetes. Subjects (N = 89) were randomized to 1) ATG and pegylated granulocyte colony-stimulating factor (GCSF), 2) ATG alone, or 3) placebo. Herein, we report 2-year area under the curve (AUC) C-peptide and HbA_1c, prespecified secondary end points, and potential immunologic correlates. The 2-year mean mixed-meal tolerance test-stimulated AUC C-peptide, analyzed by ANCOVA adjusting for baseline C-peptide, age, and sex (n = 82) with significance defined as one-sided P < 0.025, was significantly higher in subjects treated with ATG versus placebo (P = 0.00005) but not ATG/GCSF versus placebo (P = 0.032). HbA_1c was significantly reduced at 2 years in subjects treated with ATG (P = 0.011) and ATG/GCSF (P = 0.022) versus placebo. Flow cytometry analyses demonstrated reduced circulating CD4:CD8 ratio, increased regulatory T-cell:conventional CD4 T-cell ratios, and increased PD-1⁺CD4⁺ T cells following low-dose ATG and ATG/GCSF. Low-dose ATG partially preserved β-cell function and reduced HbA_1c 2 years after therapy in new-onset type 1 diabetes. Future studies should determine whether low-dose ATG might prevent or delay the onset of type 1 diabetes.

Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module for youth with Type 2 diabetes: reliability and validity

AIM

To test the measurement properties of the revised and updated Pediatric Quality of Life Inventory (PedsQL) 3.2 Diabetes Module originally developed in Type 1 diabetes in youth with Type 2 diabetes.

METHODS

The PedsQL 3.2 Diabetes Module and PedsQL Generic Core Scales were administered in a field test study to 100 young people aged 9-25 years with Type 2 diabetes. Factor analysis was conducted to determine the factor structure of the items.

RESULTS

The 15-item Diabetes Symptoms Summary Score and 12-item Type 2-specific Diabetes Management Summary Score were empirically derived through factor analysis. The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores showed acceptable to excellent reliability across the age groups tested (α = 0.85-0.94). The Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores evidenced construct validity through large effect size correlations with the Generic Core Scales Total Scale Score (r = 0.67 and 0.57, respectively). HbA_1c was correlated with the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores (r = -0.13 and -0.22). Minimal clinically important difference (MCID) scores were 5.91 and 7.39 for the Diabetes Symptoms and Type 2-specific Diabetes Management Summary Scores.

CONCLUSIONS

The PedsQL 3.2 Diabetes Module Diabetes Symptoms Summary Score and Type 2-specific Diabetes Management Summary Score exhibited satisfactory measurement properties for use as youth self-reported diabetes symptoms and diabetes management outcomes for clinical research and clinical practice for young people with Type 2 diabetes.