Impact of an evidence-based bundle intervention in the quality-of-care management and outcome of Staphylococcus aureus bacteremia

Implementation of a paediatric peripheral intravenous catheter care bundle: A quality improvement initiative

AIM

To improve paediatric peripheral intravenous catheter (PIVC) care through the implementation of care bundles.

METHODS

A pre-post study using mixed methods (clinical audit, staff survey, parent interviews) in 2016 at a tertiary paediatric hospital in Brisbane was conducted to evaluate the effectiveness of a PIVC insertion and maintenance bundle to improve PIVC insertion, promote function and support practice. Participants included children with PIVC, parents and staff inserting and managing PIVCs. A mnemonic care bundle, SUCCESS PIVCS (At insertion: Skills, Understand and prepare, Consent, Clean site, Escalate, Secure, Sign and document. During management: Prompt removal, Inspect hourly, Vein patency, Clean hands and Scrub the hub), was developed and implemented via visual aids, workshops and change champions. During audit, PIVC first-attempt insertion success, PIVC failure, PIVC dwell, escalation to senior clinicians and insertion and management procedures were measured.

RESULTS

Pre-implementation audit (n = 102) and survey (n = 117) data described high rates of PIVC failure (n = 50; 49%), difficulty obtaining equipment (n = 64; 55%) and pressure to insert (n = 50; 43%). Parent interviews (n = 15) identified lack of communication, fear, appreciation of skilled technicians and technology and care giver roles as key to improving the experience. After implementation first-attempt insertion success (45 vs. 62%; risk ratio 1.37, 95% confidence interval 1.05-1.78), first-attempt escalation to senior clinicians (junior doctor 72 vs. 41%; P = <0.001) and median PIVC dwell (40 vs. 52 h; P = 0.021) improved.

CONCLUSION

This multi-level care bundle demonstrated improvements in the insertion and management of PIVCs; however, PIVC failure remained high.

A Healthcare Improvement Intervention Combining Nucleic Acid Microarray Testing With Direct Physician Response for Management of Staphylococcus aureus Bacteremia

Background

Nucleic acid microarray (NAM) testing for detection of Staphylococcus aureus bacteremia (SAB) and S. aureus resistance gene determinants can reduce time to targeted antibiotic administration. Evidence-based management of SAB includes bedside infectious diseases (ID) consultation. As a healthcare improvement initiative at our institution, with the goal of improving management and outcomes for subjects with SAB, we implemented NAM with a process for responding to positive NAM results by directly triggered, mandatory ID consultation.

Methods

Preintervention, SAB was identified by traditional culture and results passively directed to antibiotic stewardship program (ASP) pharmacists. Postintervention, SAB in adult inpatients was identified by Verigene Gram-Positive Blood Culture test, results paged directly to ID fellow physicians, and consultation initiated immediately. In the new process, ASP assisted with management after the initial consultation. A single-center, retrospective, pre-/postintervention analysis was performed.

Results

One hundred six preintervention and 120 postintervention subjects were assessed. Time to ID consultation after notification of a positive blood culture decreased 26.0 hours (95% confidence interval [CI], 45.1 to 7.1 hours, P < .001) postintervention compared with preintervention. Time to initiation of targeted antibiotic decreased by a mean of 21.2 hours (95% CI, 31.4 to 11.0 hours, P < .001) and time to targeted antibiotics for methicillin-sensitive S. aureus decreased by a mean of 40.7 hours (95% CI, 58.0 to 23.5 hours, P < .001). The intervention was associated with lower in-hospital (13.2% to 5.8%, P = .047) and 30-day (17.9% to 8.3%, P = .025) mortality.

Conclusions

Compared with an ASP-directed response to traditionally detected SAB, an efficient physician response to NAM was associated with improved care and outcomes for SAB.

Clinical impact of an educational antimicrobial stewardship program associated with infectious diseases consultation targeting patients with cancer: Results of a 9-year quasi-experimental study with an interrupted time-series analysis

OBJECTIVES

Antibiotic stewardship programs (ASP) have already demonstrated clinical benefits. However, their effectiveness or safety in immunocompromised hosts needs to be proved.

METHODS

An ecologic quasi-experimental study was performed from January 2009 to June 2017 in the Oncology department of a tertiary-care hospital. A stable program of Infectious Diseases consultation (IDC) already existed at this unit, and an educational ASP was added in 2011. Its main intervention consisted of face-to-face educational interviews. Antibiotic consumption was assessed through quarterly Defined Daily Doses (DDD) per 100 occupied bed-days. Mortality was evaluated in patients with bloodstream infections through the quarterly incidence density per 1000 admissions, and the annual mortality rates at 7 and 30-days. Time-trends were analysed through segmented-regression analysis, and the impact of the ASP was assessed through before-after interrupted time-series analysis.

RESULTS

Mortality significantly decreased throughout the study period (-13.3% annual reduction for 7-day mortality rate, p < 0.01; -8.1% annual reduction for 30-day mortality, p = 0.03), parallel to a reduction in antibiotic consumption (quarterly reduction -0.4%, p = 0.01), especially for broader-spectrum antibiotics. The before-after study settled a significant inflexion point on the ASP implementation for the reduction of antibiotic consumption (change in level 0.95 DDD, p = 0.71; change in slope -1.98 DDD per quarter, p < 0.01). The decreasing trend for mortality before the ASP also continued after its implementation.

CONCLUSIONS

The combination of an ASP with IDC improved antibiotic use among patients with cancer, and was accompanied by a reduction of mortality of bacteraemic infections. Implementation of the ASP was necessary to effectively change antibiotic use.

The intervention by an antimicrobial stewardship team can improve clinical and microbiological outcomes of resistant gram-negative bacteria

Antibiotic stewardship (AS) improves patient outcomes and rates of antibiotic susceptibilities. However, the long-term effect of AS programs (ASPs) on mortality is unclear. This study aimed to assess the impact of bedside interventions by an AS team (AST) on clinical and microbiological outcomes. This retrospective study enrolled patients with bloodstream infections (BSI) and long-term use of broad-spectrum antibiotics (more than 7 days). The main outcomes were 30-day and in-hospital mortality of patients with BSI. The secondary outcomes were the day of therapy (DOT) and susceptibility of antipseudomonal agents. Cases were classified into two groups: the pre-ASP group comprised cases between 2011 and 2013 and the post-ASP group, between 2014 and 2016. The outcomes were then compared between the two groups. Among the patients with all BSI (n = 1187), no significant differences in 30-day mortality were observed between those in the pre-ASP and post-ASP groups. However, in-hospital mortality was significantly lower in the post-ASP group than that in the pre-ASP group (24.8% vs. 18.0%; P = 0.004). Furthermore, the 30-day and in-hospital mortality of resistant gram-negative bacteraemia was significantly lower (20.4% vs.10.5%; P = 0.04 and 28.0% vs.16.1%; P = 0.03). The DOT of broad-spectrum antibiotics decreased except that of tazobactam/piperacillin. The susceptibilities of tazobactam/piperacillin, ceftazidime, cefepime, sulbactam/cefoperazone, gentamicin, ciprofloxacin levofloxacin, imipenem and meropenem were significantly better. Interventions by the AST can improve the clinical and microbiological outcomes, especially resistant gram-negative bacteria. Furthermore, this effect of our ASP can continue for a long term.

Pharmacist-driven initiative for management of Staphylococcus aureus bacteremia using a clinical decision support system

PURPOSE

The development and implementation of a clinical decision support system (CDSS) for pharmacists to use for identification of and intervention on patients with Staphylococcus aureus bacteremia (SAB) are described.

SUMMARY

A project team consisting of 3 informatics pharmacists and 2 infectious diseases (ID) pharmacists was formed to develop the CDSS. The primary CDSS component was a scoring system that generates a score in real time for a patient with a positive blood culture for S. aureus. In addition, 4 tools were configured in the CDSS to facilitate pharmacists' workflow and documentation tasks: a patient list, a patient list report, a handoff note, and a standardized progress note. Pharmacists are required to evaluate the patient list at least once per shift to identify newly listed patients with a blood culture positive for S. aureus and provide recommendations if necessary. The CDSS was implemented over a period of 2.5 months, with a pharmacy informatics resident dedicating approximately 200 hours in total. An audit showed that the standardized progress note was completed for 100% of the patients, with a mean time to completion of 8.5 hours. Importantly, this initiative can be implemented in hospitals without specialty-trained ID pharmacists. This study provides a framework for future antimicrobial stewardship program initiatives to incorporate pharmacists into the process of providing real-time recommendations.

CONCLUSION

A pharmacist-driven patient scoring system was successfully used to improve adherence to quality performance measures for management of SAB. A pharmacist-driven CDSS can be utilized to assist in the management of SAB.

Transition from intravenous to oral antimicrobial therapy in patients with uncomplicated and complicated bloodstream infections

BACKGROUND

The role of oral antimicrobial agents in the management of bloodstream infections (BSI) is currently evolving.

OBJECTIVES

This narrative review summarizes and appraises clinical studies that examined transition from intravenous to oral antimicrobials or compared effectiveness of various oral agents for definitive therapy of uncomplicated and complicated BSI in adults.

SOURCES

Relevant English-language studies from MEDLINE (since inception) and presented abstracts at international scientific meetings (since 2017).

CONTENT

Emerging data suggest potential utility of oral switch strategy, particularly to oxazolidinones, as an alternative to standard intravenous therapy in low-risk patients with uncomplicated Staphylococcus aureus BSI. Moreover, results of recent randomized clinical trials are promising that combination oral regimens may play a role in antimicrobial management of complicated Gram-positive BSI, including infective endocarditis, septic arthritis and osteomyelitis. Whereas oral fluoroquinolones have been used successfully for decades in both uncomplicated and complicated Gram-negative BSI, recent studies suggest that trimethoprim-sulfamethoxazole and aminopenicillins represent alternative oral options in uncomplicated Enterobacteriaceae BSI. Oral azoles have been used for definitive therapy of Candida species BSI and are currently recommended by the international management guidelines.

IMPLICATIONS

Recent studies demonstrate that early transition from intravenous to oral therapy is a feasible and effective strategy in most patients with BSI due to Gram-negative bacteria, obligate anaerobic bacteria and Candida species. Oral antimicrobial combinations may be considered in select patients with complicated Gram-positive BSI after 10-14 days of intravenous therapy. Future studies will determine the role of oral agents for switch therapy in uncomplicated Gram-positive BSI.

Influence of a resin-based blood culture medium on the time to clearance of methicillin-susceptible Staphylococcus aureus bloodstream infection - A retrospective cohort study

We evaluated the improved sensitivity and time to detection of new resin-based blood culture (BC) media in Staphylococcus aureus bloodstream infection. We observed a significantly longer duration of bacteremia and shorter time to detection compared to traditional charcoal-based BC media, which may influence diagnostic work-up and treatment duration.

Cefazolin versus anti-staphylococcal penicillins for the treatment of patients with Staphylococcus aureus bacteraemia

BACKGROUND

For patients with bacteraemia caused by methicillin-sensitive Staphylococcus aureus anti-staphylococcal penicillins (ASPs) or cefazolin are agents of choice. While ASPs are potentially nephrotoxic, cefazolin may be less effective in some S. aureus strains due to an inoculum effect.

OBJECTIVES

To perform a systematic literature review and meta-analysis assessing current evidence comparing cefazolin with ASPs for patients with S. aureus bacteraemia (SAB).

METHODS

We searched MEDLINE, ISI Web of Science (Science Citation Index Expanded) and the Cochrane Database as well as clinicaltrials.gov from inception to 26 June 2018. All studies investigating the effects of cefazolin versus ASP in patients with methicillin-sensitive SAB were eligible for inclusion regardless of study design, publication status or language. Additional information was requested by direct author contact. A meta-analysis to estimate relative risks (RRs) with the corresponding 95% confidence intervals (CIs) was performed. Statistical heterogeneity was estimated using I². The primary endpoint was 90-day all-cause mortality. The Newcastle-Ottawa Scale (NOS) and Grading of Recommendations Assessment, Development and Evaluation (GRADE) were used for study and data quality assessment.

RESULTS

Fourteen non-randomized studies were included. Seven reported the primary endpoint (RR 0.71 (0.50, 1.02), low quality of evidence). Cefazolin treatment may be associated with lower 30-day mortality rates (RR 0.70 (0.54, 0.91), low quality of evidence) and less nephrotoxicity (RR 0.36 (0.21, 0.59), (low quality of evidence)). We are uncertain whether cefazolin and ASP differ regarding treatment failure/relapse as the quality of the evidence has been assessed as very low (RR of 0.84 (0.59, 1.18)). For patients with endocarditis (RR 0.71 (0.12, 4.05)) or abscesses (RR 1.17 (0.30, 4.63)), cefazolin treatment may be associated with equal 30-day and 90-day mortality (low quality of evidence).

CONCLUSIONS

Cefazolin seemed to be at least equally as effective as ASPs while being associated with less nephrotoxicity.

Infectious diseases consultation improves key performance metrics in the management of Staphylococcus aureus bacteremia: A multicentre cohort study

BACKGROUND

Staphylococcus aureus bacteremia (SAB) is associated with significant morbidity and mortality. We sought to identify factors associated with infectious diseases consultation (IDC) and understand how IDC associates with SAB patient management and outcomes.

METHODS

A multicentre retrospective study was performed between 2012 and 2014 in a large Canadian Health Zone in order to determine factors associated with IDC and performance of key quality of care determinants in SAB management and clinical outcomes. Factors subject to quality of care determinants were established a priori and studied for associations with IDC and 30-day all-cause mortality using multivariable analysis.

RESULTS

Of 961 SAB episodes experienced by 892 adult patients, 605 episodes received an IDC. Patients receiving IDC were more likely to have prosthetic valves and joints and to have community-acquired and known sources of SAB, but increasing age decreased IDC occurrence. IDC was the strongest independent predictor for quality of care performance metrics, including repeat blood cultures and echocardiography. Mortality at 30 days was 20% in the cohort, and protective factors included IDC, achievement of source control, targeted therapy within 48 hours, and follow-up blood cultures but not the performance of echocardiography.

CONCLUSIONS

There were significant gaps between the treatments and investigations that patients actually received for SAB and what is considered the optimal management of their condition. IDC is associated with improved attainment of targeted SAB quality of care determinants and reduced mortality rates. Based on our findings, we propose a policy of mandatory IDC for all cases of SAB to improve patient management and outcomes.

Impact of an Unsolicited, Standardized Form-Based Antimicrobial Stewardship Intervention to Improve Guideline Adherence in the Management of Staphylococcus aureus Bacteremia

Background

Antimicrobial stewardship programs (ASPs) improve Staphylococcus aureus bacteremia (SAB) management. The objective of the current study was to evaluate the effect of unsolicited prospective audit and feedback (PAF) using a standardized SAB bundle form on the management of SAB.

Methods

Multicenter, pre-post quasi-experimental study of inpatients with SAB. The ASP developed an evidence-based SAB management bundle that included recommendations for infectious diseases consultation, blood culture clearance, appropriate empiric and definitive therapy, echocardiography, adequate treatment duration, and source control where applicable. ASP pharmacists performed PAF using a standardized form outlining bundle components. The primary outcome was bundle component adherence. Secondary outcomes were length of stay, 30-day readmission rate, and in-hospital and 30-day mortality rates.

Results

A total of 199 patients were included (preintervention group, 62; intervention group, 137). Bundle implementation with PAF resulted in significant improvements in infectious diseases consultation (56.5% in preintervention vs 93.4% in intervention group), appropriate definitive antibiotic therapy (83.9% vs 99.3%), ordering echocardiography (72.6% vs 95.6%), and adequate treatment duration (87.0% vs 100%) (all P < .001). Overall bundle adherence increased by 43.8% (P < .001). Readmission and 30-day mortality rates decreased, but this difference did not reach statistical significance.

Conclusions

Unsolicited PAF using a standardized SAB management bundle significantly improved adherence to evidence-based recommendations. This simple yet effective ASP-driven intervention can ensure consistent management of a highly morbid infection.

Impact of infectious diseases consultation on the outcome of patients with bacteraemia

Bacteraemia or bloodstream infections (BSI) are associated with much morbidity and mortality. Management of patients with bacteraemia is complex, and the increase in immunosuppressed patients and multidrug-resistant organisms poses additional challenges. The objective of this review is to assess the available published information about the impact of different aspects of management on the outcome of patients with BSI, and, specifically, the importance of infectious diseases specialists (IDS) consultation. The impact of management by IDS on different aspects, including interpretation of newer rapid techniques, early evaluation and treatment, and follow up, are reviewed. Overall, the available data suggest that IDS intervention improves the management and outcome of patients with BSI, either through consultation or structured unsolicited interventions in the context of multidisciplinary bacteraemia programmes.

How automatic notification of infectious disease specialists impacted the management of Staphylococcus aureus bacteremia in a community hospital setting

Objective: The objective of this study was to review the impact of an automatic email notification to infectious disease consultants.

Design: Cases were identified from a community hospital system microbiology database by at least one positive blood culture. Records were reviewed both before (2013 and 2014) and after (2015 and 2016) the implementation of the automated email system (intervention). Prior to this policy, consultation with the infectious disease (ID) specialist was at the discretion of the primary team.

Results: There were no significant differences in 30-day mortality between the two groups (18 vs 20%, p = 0.10). However, a trend of shorter hospital stays (12.2 vs 9.5 days, p = 0.03) and reduced 30 day readmissions (40% vs 19%, p = 0.03) was observed and antibiotics prescribed for complicated cases was more appropriate (57% vs 85%, p = 0.004).

Conclusions: In this study population, the implementation of an automatic email generator to ID specialists was associated with a shorter hospital length of stay, less 30-day readmissions and more appropriate length of antibiotics prescribed in complicated cases of SAB. The authors recommend future studies replicating the methodology employed here with larger sample sizes before consideration of employing a similar automatic email ID consult generation at other health systems.

Intravenous to oral switch therapy in cancer patients with catheter-related bloodstream infection due to methicillin-sensitive Staphylococcus aureus: A single-center retrospective observational study

The most common complication in cancer patients is catheter-related bloodstream infection (CRBSI), of which Staphylococcus aureus is a common pathogen. Although S. aureus CRBSI patients are recommended for prolonged intravenous therapy, this is often not feasible. We assessed the effectiveness of switching from intravenous to oral antimicrobial therapy in cancer patients with CRBSI due to methicillin-sensitive S. aureus (MSSA). We conducted a retrospective observational study of 60 patients at one tertiary-care cancer center between April 2005 and March 2016. Patients who received effective intravenous (IV) antibiotics for at least 10 days (IV group) were compared to the IV group of patients who had switched to effective oral (PO) antibiotics after IV treatment for at least 10 days (IV + PO group). The primary endpoint was all-cause mortality within 90 days. Univariate and propensity score-adjusted multivariate logistic regression analyses using variables likely to influence the outcomes were performed. Of the 60 patients, 32 (53.3%) and 28 (46.7%) were in the IV and IV + PO groups, respectively. The median antibiotic treatment durations in the IV and IV + PO groups were 17 (13-31) and 33 (26-52) days, respectively (p<0.001). The 90-day mortality in the IV and IV + PO groups were 53.1% (17/32) and 10.7% (3/28), respectively (p = 0.001). Univariate logistic regression model showed that the odds ratios of oral switch therapy for 90-day mortality was 0.106 (95% confidence interval [CI]: 0.027-0.423; p = 0.001). The propensity score-adjusted multivariate logistic regression model estimated the odds ratios of oral switched therapy for 90-day mortality as 0.377 (95% CI: 0.037-3.884; p = 0.413). Our results suggest that oral switch therapy was not associated with mortality in cancer patients with CRBSI due to MSSA compared with no oral switch therapy. Oral switch therapy may be a reasonable option for patients with CRBSI due to MSSA.

Impact on mortality of adherence to evidence-based interventions in patients with catheter-related bloodstream infection due to methicillin-sensitive Staphylococcus aureus

BACKGROUND

Recent studies have demonstrated improved survival when the management of Staphylococcus aureus bloodstream infection (BSI) is compliant with evidence-based therapeutic interventions. Whether this effect extends to low-risk sources, such as catheter-related BSI, remains unclear.

METHODS

We retrospectively included 225 episodes of methicillin-sensitive S. aureus catheter-related BSI diagnosed in our centre during two non-consecutive periods: 2002-2004 (first period (101 episodes)) and 2009-2013 (second period (124 episodes)). We evaluated the adherence (percentage of compliance = (no. of interventions performed/no. of interventions recommended) × 100) to the following bundle: early catheter removal (≤72 hours), early initiation of appropriate antibiotic therapy, adequate sampling of follow-up blood cultures, transthoracic echocardiography (TTE) during hospitalization and adequate duration of therapy.

RESULTS

Patients in the second period had a higher burden of comorbidities and more severe underlying conditions. All-cause 30-day mortality was 9.3%, with a significant difference between the first and second periods (13.9% versus 5.6%; p value = .035). Bundle adherence was significantly higher in the second period, particularly for follow-up blood cultures (26.7% versus 48.4%; p value = .001), performance of TTE (45.5% versus 84.7%; p value < .001) and appropriate duration of therapy (34.7% versus 50.0%; p value = .022). Bundle adherence ≥ 55% was associated with lower 30-day mortality (hazard ratio: 0.31; 95% confidence interval: 0.13-0.76). This effect remained significant across propensity score-based models adjusted for septic shock, study period and underlying conditions.

CONCLUSIONS

There was a survival benefit in adhering to a bundle of evidence-based interventions in the specific setting of catheter-related BSI due to methicillin-sensitive S. aureus.

The updated Charlson comorbidity index is a useful predictor of mortality in patients with Staphylococcus aureus bacteraemia

The objective was to compare the performance of the updated Charlson comorbidity index (uCCI) and classical CCI (cCCI) in predicting 30-day mortality in patients with Staphylococcus aureus bacteraemia (SAB). All cases of SAB in patients aged ⩾14 years identified at the Microbiology Unit were included prospectively and followed. Comorbidity was evaluated using the cCCI and uCCI. Relevant variables associated with SAB-related mortality, along with cCCI or uCCI scores, were entered into multivariate logistic regression models. Global model fit, model calibration and predictive validity of each model were evaluated and compared. In total, 257 episodes of SAB in 239 patients were included (mean age 74 years; 65% were male). The mean cCCI and uCCI scores were 3.6 (standard deviation, 2.4) and 2.9 (2.3), respectively; 161 (63%) cases had cCCI score ⩾3 and 89 (35%) cases had uCCI score ⩾4. Sixty-five (25%) patients died within 30 days. The cCCI score was not related to mortality in any model, but uCCI score ⩾4 was an independent factor of 30-day mortality (odds ratio, 1.98; 95% confidence interval, 1.05-3.74). The uCCI is a more up-to-date, refined and parsimonious prognostic mortality score than the cCCI; it may thus serve better than the latter in the identification of patients with SAB with worse prognoses.

Survival following Staphylococcus aureus bloodstream infection: A prospective multinational cohort study assessing the impact of place of care

BACKGROUND

Staphylococcus aureus bloodstream infection (SAB) is a common, life-threatening infection with a high mortality. Survival can be improved by implementing quality of care bundles in hospitals. We previously observed marked differences in mortality between hospitals and now assessed whether mortality could serve as a valid and easy to implement quality of care outcome measure.

METHODS

We conducted a prospective observational study between January 2013 and April 2015 on consecutive, adult patients with SAB from 11 tertiary care centers in Germany, South Korea, Spain, Taiwan, and the United Kingdom. Factors associated with mortality at 90 days were analyzed by Cox proportional hazards regression and flexible parametric models.

RESULTS

1851 patients with a median age of 66 years (64% male) were analyzed. Crude 90-day mortality differed significantly between hospitals (range 23-39%). Significant variation between centers was observed for methicillin-resistant S. aureus, community-acquisition, infective foci, as well as measures of comorbidities, and severity of disease. In multivariable analysis, factors independently associated with mortality at 90 days were age, nosocomial acquisition, unknown infective focus, pneumonia, Charlson comorbidity index, SOFA score, and study center. The risk of death varied over time differently for each infective focus. Crude mortality differed markedly from adjusted mortality.

DISCUSSION

We observed significant differences in adjusted mortality between hospitals, suggesting differences in quality of care. However, mortality is strongly influenced by patient mix and thus, crude mortality is not a suitable quality indicator.

Unsolicited consultation by infectious diseases specialist improves outcomes in patients with bloodstream infection: A prospective cohort study

INTRODUCTION

The objective of this study was to evaluate the impact of an intervention based on unsolicited consultations by an infectious diseases specialist (IDS) on the adequacy of antimicrobial treatment and mortality in patients with BSI.

METHODS

A prospective cohort study was performed in a 410-bed hospital. An intervention based on unsolicited consultation by an IDS for patients with BSI was performed only on days when an IDS was available. Outcomes were the percentage of days on optimal antimicrobial treatment (PDOAT) and mortality. Analyses were performed by linear regression and multivariate logistic regression.

RESULTS

Of 400 episodes of BSI included, 292 received the intervention. The median (interquartile range) PDOAT among those with and without the intervention was 93 (6-100) and 0 (0-53), respectively. The intervention was independently associated with a higher PDOAT (r = 0.5; p < 0.001) but not with mortality. The IDS recommendations were followed in full in 183 episodes, and not in 109. Mortality was 10.4% and 27.6%, respectively. Adherence to recommendations was associated with lower mortality (adjusted OR = 0.3; 95% CI: 0.1-0.5).

CONCLUSIONS

An intervention based on unsolicited IDS consultation for BSI episodes was associated with improved use of antibiotics and, when the recommendations were fully followed, with lower mortality.

[Bacterial sepsis : Diagnostics and calculated antibiotic therapy]

The mortality of patients with sepsis and septic shock is still unacceptably high. An effective antibiotic treatment within 1 h of recognition of sepsis is an important target of sepsis treatment. Delays lead to an increase in mortality; therefore, structured treatment concepts form a rational foundation, taking relevant diagnostic and treatment steps into consideration. In addition to the assumed focus and individual risks of each patient, local resistance patterns and specific problem pathogens must be taken into account for selection of anti-infection treatment. Many pathophysiological alterations influence the pharmacokinetics of antibiotics during sepsis. The principle of standard dosing should be abandoned and replaced by an individual treatment approach with stronger weighting of the pharmacokinetics/pharmacodynamics (PK/PD) index of the substance groups. Although this is not yet the clinical standard, prolonged (or continuous) infusion of beta-lactam antibiotics and therapeutic drug monitoring (TDM) can help to achieve defined PK targets. Prolonged infusion is sufficient without TDM but for continuous infusion TDM is basically necessary. A further argument for individual PK/PD-oriented antibiotic approaches is the increasing number of infections due to multidrug resistant pathogens (MDR) in the intensive care unit. For effective treatment antibiotic stewardship teams (ABS team) are becoming more established. Interdisciplinary cooperation of the ABS team with infectiologists, microbiologists and clinical pharmacists leads not only to a rational administration of antibiotics but also has a positive influence on the outcome. The gold standards for pathogen detection are still culture-based detection and microbiological resistance testing for the various antibiotic groups. Despite the rapid investigation time, novel polymerase chain reaction (PCR)-based procedures for pathogen identification and resistance determination, are currently only an adjunct to routine sepsis diagnostics due to the limited number of studies, high costs and limited availability. In complicated septic courses with multiple anti-infective treatment or recurrent sepsis, PCR-based procedures can be used in addition to therapy monitoring and diagnostics. Novel antibiotics represent potent alternatives in the treatment of MDR infections. Due to the often defined spectrum of pathogens and the practically absent resistance, they are suitable for targeted treatment of severe MDR infections (therapy escalation).

Disease-based antimicrobial stewardship: a review of active and passive approaches to patient management

Although new antimicrobial stewardship programmes (ASPs) often begin by targeting the reduction of antimicrobial use, an increasing focus of ASPs is to improve the management of specific infectious diseases. Disease-based antimicrobial stewardship emphasizes improving patient outcomes by optimizing antimicrobial use and increasing compliance with performance measures. Directing efforts towards the comprehensive management of specific infections allows ASPs to promote the shift in healthcare towards improving quality, safety and patient outcome metrics for specific diseases. This review evaluates published active and passive disease-based antimicrobial stewardship interventions and their impact on antimicrobial use and associated patient outcomes for patients with pneumonia, acute bacterial skin and skin structure infections, bloodstream infections, urinary tract infections, asymptomatic bacteriuria, Clostridium difficile infection and intra-abdominal infections. Current literature suggests that disease-based antimicrobial stewardship effects on medical management and patient outcomes vary based on infectious disease syndrome, resource availability and intervention type.

The management and outcomes of Staphylococcus aureus bacteraemia at a South African referral hospital: A prospective observational study

OBJECTIVES

Data on the management and outcomes of Staphylococcus aureus bacteraemia (SAB) in resource-limited settings are limited. The aim of this study was to describe a cohort of South African patients with SAB, and explore the factors associated with complicated infection and death.

METHODS

This was a prospective observational study of patients over the age of 13 years admitted to a South African referral hospital with SAB.

RESULTS

One hundred SAB infection episodes occurring in 98 patients were included. SAB was healthcare-associated in 68.4%; 24.0% of all cases were caused by methicillin-resistant S. aureus (MRSA). Ninety-day mortality was 47.0%, with 83.3% of deaths attributable to SAB. There was a trend towards increased 90-day mortality with MRSA infection (odds ratio (OR) 1.28, 95% confidence interval (CI) 1.0-15.1) and the presence of comorbidities (OR 4.1, 95% CI 1.0-21.6). The risk of complicated infection was higher with non-optimal definitive antibiotic therapy (OR 8.5, 95% CI 1.8-52.4), female sex (OR 3.8, 95% CI 1.1-16.3), and community-acquired infection (OR 7.4, 95% CI 2.0-33.1). Definitive antibiotic therapy was non-optimal in 22.6% of all cases.

CONCLUSIONS

SAB-related mortality was high. A large proportion of cases may be preventable, and there is a need for improved antibiotic management.

An Automated, Pharmacist-Driven Initiative Improves Quality of Care for Staphylococcus aureus Bacteremia

Background

Infectious diseases (ID) consultation and antimicrobial stewardship intervention have been shown to improve the management of Staphylococcus aureus bacteremia (SAB). As the workload of antimicrobial stewardship programs (ASPs) continues to increase, ASPs must find a way to maximize the efficiency of the program while optimizing patient outcomes. The objective of this study was to evaluate the impact of incorporating health informatics into the management of SAB via a pharmacist-driven initiative.

Methods

Retrospective, single-center quasi-experimental study of hospitalized patients with SAB. During the intervention period, pharmacists were alerted to patients with SAB via a patient scoring tool integrated into the electronic medical record. Pharmacists utilized the scoring tool and the institution's evidence-based practice guideline to make standardized recommendations to promote adherence to SAB quality-of-care measures and encourage ID consultation. The primary outcome was overall compliance along with adherence to individual quality-of-care components. Secondary clinical outcomes were also analyzed.

Results

In sum, 84 patients were identified for study inclusion, 45 in the pre-intervention and 39 in the intervention group. As a whole, all 4 quality-of-care components for the management of SAB were significantly more frequently adhered to in the intervention group (68.9% vs 92.3%; P = .008). The incidence of ID consult improved significantly by almost 20% in the intervention group (75.6% vs 94.9%, P = .015). No statistically significant differences in duration of bacteremia, length-of-stay, infection-related length-of-stay, or readmission were observed between the groups. The incidence of all-cause mortality was 6-fold higher in the pre- intervention group compared to the intervention group (15.6% vs 2.6%, P = .063).

Conclusion

An automated, pharmacist-driven intervention for the management of patients with SAB demonstrated a significant improvement in patients receiving an ID consult, targeted antimicrobial therapy, and adherence to all SAB quality-of-care measures. As antimicrobial stewardship becomes a mandatory aspect of healthcare in all hospitals in the United States, ASPs will be forced to find ways to provide more efficient, impactful, disease state-based patient care. Our study provides the framework for and data to support this intervention in one of the most clinically important infectious diseases.

The California Multidrug-Resistant Tuberculosis Consult Service: a partnership of state and local programs

Background: The US Centers for Disease Control and Prevention recommend expert consultation for multi-drug-resistant tuberculosis (MDR-TB) cases. In 2002, the California MDR-TB Service was created to provide expert MDR-TB consultations. We describe the characteristics, treatment outcomes and management of patients referred to the Service. Methods: Surveillance data were used for descriptive analysis of cases, with consultation during July 2002-December 2012. Clinical consultation data and modified World Health Organization indicators were used to assess the care and management of cases, with consultation from January 2009 to December 2012. Results: Of 339 MDR-TB patients, 140 received a consultation. The proportion of patients receiving a consultation increased from 12% in 2002 to 63% in 2012. There were 24 pre-extensively drug-resistant TB and 5 patients with extensively drug-resistant TB. The majority (n = 123, 88%) completed treatment, 5 (4%) died, 7 (5%) moved before treatment completion, 4 (3%) stopped treatment due to an adverse event and 1 (1%) had an unknown outcome. Indicator data showed that 86% underwent rapid molecular drug susceptibility testing, 98% received at least four drugs to which they had known or presumed susceptibility, and 93% culture converted within 6 months. Conclusions: Consultations with the MDR-TB Service increased over time. Results highlight successful treatment and indicator outcomes.

Morbidity from in-hospital complications is greater than treatment failure in patients with Staphylococcus aureus bacteraemia

BACKGROUND

Various studies have identified numerous factors associated with poor clinical outcomes in patients with Staphylococcus aureus bacteraemia (SAB). A new study was created to provide deeper insight into in-hospital complications and risk factors for treatment failure.

METHODS

Adult patients hospitalised with Staphylococcus aureus bacteraemia (SAB) were recruited prospectively into a multi-centre cohort. The primary outcome was treatment failure at 30 days (composite of all-cause mortality, persistent bacteraemia, or recurrent bacteraemia), and secondary measures included in-hospital complications and mortality at 6- and 12-months. Data were available for 222 patients recruited from February 2011 to December 2012.

RESULTS

Treatment failure at 30-days was recorded in 14.4% of patients (30-day mortality 9.5%). Multivariable analysis predictors of treatment failure included age > 70 years, Pitt bacteraemia score ≥ 2, CRP at onset of SAB > 250 mg/L, and persistent fevers after SAB onset; serum albumin at onset of SAB, receipt of appropriate empiric treatment, recent healthcare attendance, and performing echocardiography were protective. 6-month and 12-month mortality were 19.1% and 24.2% respectively. 45% experienced at least one in-hospital complication, including nephrotoxicity in 19.5%.

CONCLUSIONS

This study demonstrates significant improvements in 30-day outcomes in SAB in Australia. However, we have identified important areas to improve outcomes from SAB, particularly reducing renal dysfunction and in-hospital treatment-related complications.

Automatic notification and infectious diseases consultation for patients with Staphylococcus aureus bacteremia

Observational studies suggest that Infectious Diseases (ID) consultation is associated with improved outcomes for patients with Staphylococcus aureus bacteremia (SAB), but few studies have sought to standardize timely ID consultation through automatic notification by the Microbiology laboratory. In this 3-year quasi-experimental evaluation, introduction of this change resulted in increased ID consultation for SAB (70% versus 100%, P < 0.001) and decreased time to consultation (14.5 versus 4 h, P < 0.0001). Adherence to Quality of Care Indicators (QCIs) increased (45% versus 87%, P < 0.0002), transfer to intensive care unit decreased (38% versus 16%, P = 0.03), while decrease in 30-day readmission or death did not reach statistical significance (33% versus 27%, P = 0.5). Automatic notification and ID consultation for patients with SAB are a feasible system for ensuring improved adherence to established QCIs.

Evaluation of treatment outcomes of patients with MRSA bacteremia following antimicrobial stewardship programs with pharmacist intervention

BACKGROUND

Methicillin-resistant Staphylococcus aureus bacteremia (MRSA-B) is associated with high mortality and implementing an appropriate antimicrobial stewardship (AS) program with treatment intervention is essential. The aim of this study was to evaluate the impact of AS with pharmacist intervention on patients with MRSA-B.

METHODS

Patients who were diagnosed with MRSA-B between January 2012 and April 2013 were defined as the pre-intervention group, while those diagnosed between May 2013 and December 2015 were defined as the intervention group (ie, AS with pharmacist intervention). The factors affecting bundle compliance rates and mortality were analysed.

RESULT

The pre-intervention group comprised 43 patients and the intervention group comprised 51 patients. Bundle compliance rates were estimated as follows in the intervention group: an increase was observed in the appropriate duration of therapy (from 44.8% to 72.1%, P = .027), incidences of the early use of anti-MRSA drugs (from 62.3% to 82.4%, P = .038), and the number of negative follow-up blood cultures (from 40.0% to 80.0%, P < .001), and a decrease was observed for 30-day mortality (from 41.8% to 21.6%, P = .044) and hospital mortality (from 58.1% to 27.5%, P = .003). In multivariate analysis, the intervention group was independent of 30-day mortality and hospital mortality risk reduction factors (odds ratio [OR], 0.33; 95% confidence interval [CI], 0.12-0.86, and OR, 0.20; 95% CI, 0.07-0.53).

CONCLUSIONS

AS programs with pharmacist intervention improve mortality in patients with MRSA-B.

Management of bloodstream infections by infection specialists in France and Germany: a cross-sectional survey

INTRODUCTION

Bloodstream infections (BSI) are frequent infections worldwide. Our objective was to explore variation in the management of patients with BSI by infection specialists in France and Germany.

METHODS

This work is part of an international ESCMID cross-sectional internet-based questionnaire survey that was opened from December 2016 to February 2017. All hospital-based infection specialists, senior or trainees, giving at least weekly advice on positive blood cultures could participate. Their practices were evaluated using six clinical vignettes presenting an uncomplicated BSI due to different pathogens.

RESULTS

A hundred and ninety-six professionals (125 from Germany and 71 from France) participated. Systematic expert advice for positive blood cultures was more often available in Germany as compared with France (73 vs. 56%, p = 0.004). In Germany, the professional providing the expert advice was more often a microbiologist or a pharmacist as compared with France (p = 0.001 and p = 0.037, respectively) where it was more often an infectious diseases specialist. Fewer German respondents reported to advise systematic IV-oral switch of antibiotic therapy. German respondents also recommended less often combination therapy: for example for Enterococcus faecalis (64 vs. 43%, p = 0.015), ESBL E. coli (94 vs. 67%, p < 0.001) and Pseudomonas aeruginosa (76 vs. 37%, p < 0.001). Overall, management of candidaemia was more often compliant with the IDSA guidelines in France as compared with Germany, but no difference was noted for MRSA bacteraemia.

CONCLUSION

Our survey shows that wide variations exist between two neighboring countries in the recommendations by infection specialists for the management of BSI. International guidelines are needed.

Management of bloodstream infections by infection specialists: an international ESCMID cross-sectional survey

Bloodstream infections (BSIs) are common, however international guidelines are available only for methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and candidaemia. This international ESCMID cross-sectional survey, open from December 2016 to February 2017, explored the management of BSIs by infection specialists. All infection specialists (senior or trainees) giving at least weekly advice on positive blood cultures could participate. Their practices were evaluated using six clinical vignettes presenting uncomplicated BSI cases. A total of 616 professionals from 56 countries participated [333/616 (54%) infectious diseases specialists, 188/616 (31%) clinical microbiologists], of whom 76% (468/616) were members of an antimicrobial stewardship team. Large variations in practice were noted, in particular for the Escherichia coli, Enterococcus faecalis and Pseudomonas aeruginosa vignettes. Echocardiography was considered standard of care by 81% (373/459) of participants for MRSA, 78% (400/510) for methicillin-susceptible S. aureus and 60% (236/395) for Candida albicans. Antimicrobial combination therapy was recommended by 2% (8/360) of respondents for C. albicans, 11% (43/378) for E. coli, 27% (114/420) for MRSA and 39% (155/393) for E. faecalis. Intravenous-to-oral switch was considered in 68% (285/418) for MRSA, 79% (306/388) for E. faecalis, 72% (264/366) for P. aeruginosa and 75% (270/362) for C. albicans. In multivariable analysis, IDSA guideline-compliant practice was more frequent among participants belonging to an antimicrobial stewardship team (aOR = 1.7, P = 0.018 for the MRSA vignette; and aOR = 2.0, P = 0.008 for the candidaemia vignette). This survey showed large variations in practice among infection specialists. International guidelines on management of BSI are urgently needed.

Impact of Staphylococcus aureus phenotype and genotype on the clinical characteristics and outcome of infective endocarditis. A multicentre, longitudinal, prospective, observational study

OBJECTIVE

We aimed to evaluate the impact of Staphylococcus aureus phenotype (vancomycin MIC) and genotype (agr group, clonal complex CC) on the prognosis and clinical characteristics of infective endocarditis (IE).

METHODS

We performed a multicentre, longitudinal, prospective, observational study (June 2013 to March 2016) in 15 Spanish hospitals. Two hundred and thirteen consecutive adults (≥18 years) with a definite diagnosis of S. aureus IE were included. Primary outcome was death during hospital stay. Main secondary end points were persistent bacteraemia, sepsis/septic shock, peripheral embolism and osteoarticular involvement.

RESULTS

Overall in-hospital mortality was 37% (n = 72). Independent risk factors for death were age-adjusted Charlson co-morbidity index (OR 1.20; 95% CI 1.08-1.34), congestive heart failure (OR 3.60; 95% CI 1.72-7.50), symptomatic central nervous system complication (OR 3.17; 95% CI 1.41-7.11) and severe sepsis/septic shock (OR 4.41; 95% CI 2.18-8.96). In the subgroup of methicillin-susceptible S. aureus IE (n = 173), independent risk factors for death were the age-adjusted Charlson co-morbidity index (OR 1.17; 95% CI 1.03-1.31), congestive heart failure (OR 3.39; 95% CI 1.51-7.64), new conduction abnormality (OR 4.42; 95% CI 1.27-15.34), severe sepsis/septic shock (OR 5.76; 95% CI 2.57-12.89) and agr group III (OR 0.27; 0.10-0.75). Vancomycin MIC ≥1.5 mg/L was not independently associated with death during hospital nor was it related to secondary end points. No other genotype variables were independently associated with in-hospital death.

CONCLUSIONS

This is the first prospective study to assess the impact of S. aureus phenotype and genotype. Phenotype and genotype provided no additional predictive value beyond conventional clinical characteristics. No evidence was found to justify therapeutic decisions based on vancomycin MIC for either methicillin-resistant or methicillin-susceptible S. aureus.

Risk factors for the appearance of secondary foci of infection in children with community-acquired Staphylococcus aureus bacteraemia. Cohort study 2010-2016

INTRODUCTION

Community-acquired Staphylococcus aureus (SA) bacteraemia is a common cause of hospitalisation in children. The occurrence of secondary foci (SF) of SA infection is associated with higher morbidity and mortality.

OBJECTIVES

To identify risk factors for SF of infection in children with community-acquired SA bacteraemia.

MATERIAL AND METHODS

Prospective cohort. All children aged from 30 days to 16 years admitted to a paediatric referral hospital between January 2010 and December 2016 for community-acquired infections, with SA isolated in blood cultures, were included. Microbiological, demographic and clinical characteristics were compared, with or without SF infection after 72hours of hospitalisation.

RESULTS

A total of 283 patients were included, 65% male (n=184), with a median age of 60 months (IQR: 30-132). Seventeen per cent (n=48) had at least one underlying disease and 97% (n=275) had some clinical focus of infection, the most common being: osteoarticular 55% (n=156) and soft tissue abscesses 27% (n=79). A total of 65% (n=185) were resistant to methicillin. A SF of infection was found in 16% of patients (n=44). The SF identified were pneumonia 73% (n=32), osteoarticular 11% (n=5), soft tissue 11% (n=5) and central nervous system 5% (n=2). In the multivariate analysis, the persistence of positive blood cultures after the fifth day (OR: 2.40, 95%CI: 1.07-5.37, P<0.001) and sepsis (OR: 17.23, 95%CI 5.21-56.9, P<0.001) were predictors of SF. There was no association with methicillin sensitivity.

CONCLUSIONS

In this cohort, methicillin-resistant SA infections predominated. The occurrence of SF of infection was associated with the persistence of bacteraemia after the fifth day and sepsis on admission.

Criteria for Identifying Patients With Staphylococcus aureus Bacteremia Who Are at Low Risk of Endocarditis: A Systematic Review

This systematic review examines the methods and results of recent studies reporting clinical criteria able to identify patients with Staphylococcus aureus bacteremia who are at very low risk of endocarditis. We searched PubMed, EMBASE, and the Cochrane Collaboration CENTRAL database for articles published after March 1994 using a combination of MeSH and free text search terms for S. aureus AND bacteremia AND endocarditis. Studies were included if they presented a combination of clinical and microbiological criteria with a negative likelihood ratio of ≤0.20 for endocarditis. We found 8 studies employing various criteria and reference standards whose criteria were associated with negative likelihood ratios between 0.00 and 0.19 (corresponding to 0%-5% risk of endocarditis at 20% background prevalence). The benefit of echocardiography for patients fulfilling these criteria is uncertain.

Adherence rate of quality-of-care indicators for Staphylococcus aureus bacteremia is extremely low in Japanese emergency and critical care departments: a multicenter retrospective observational study

Aim

Staphylococcus aureus bacteremia causes significant morbidity and mortality and requires specific management to prevent complications. Most studies evaluating quality of care have been carried out in Europe and North America, and accurate epidemiological data are lacking in Asia. We aimed to describe the epidemiology and evaluate the quality of care for S. aureus bacteremia in Japan.

Methods

From February 2011 to January 2014, we undertook a multicenter retrospective observational study in 10 departments of emergency and critical care in Japan. We included 118 hospitalized adult patients with S. aureus bacteremia and evaluated three quality‐of‐care indicators: follow‐up blood culture, treatment duration, and echocardiography.

Results

The mean age of the patients was 63.5 ± 17.0 years. The major source of bacteremia was pneumonia (n = 22, 19%), followed by skin and soft tissue infection (n = 18, 15%). Thirty patients (25%) died in the hospital. Follow‐up blood culture was performed in 21/112 patients (19%). The duration of antimicrobial treatment was sufficient in 49/87 patients (56%). Echocardiography for patients with clinical indication was undertaken in 39/59 patients (66%). Any of the three indicators were inadequate in 101/118 (86%).

Conclusion

The rate of adequate care for S. aureus bacteremia is low in Japan. The low adherence rate for follow‐up blood culture was particularly notable. Staphylococcus aureus bacteremia can be an important target of quality improvement interventions.

Appropriate antibiotic use reduces length of hospital stay

Objectives

To define appropriate antibiotic use in hospitalized adults treated for a bacterial infection, we previously developed and validated a set of six generic quality indicators (QIs) covering all steps in the process of antibiotic use. We assessed the association between appropriate antibiotic use, defined by these QIs, and length of hospital stay (LOS).

Methods

An observational multicentre study in 22 hospitals in the Netherlands included 1890 adult, non-ICU patients using antibiotics for a suspected bacterial infection. Performance scores were calculated for all QIs separately (appropriate or not), and a sum score described performance on the total set of QIs. We divided the sum scores into two groups: low (0%-49%) versus high (50%-100%). Multilevel analyses, correcting for confounders, were used to correlate QI performance (single and combined) with (log-transformed) LOS and in-hospital mortality.

Results

The only single QI associated with shorter LOS was appropriate intravenous-oral switch (geometric means 6.5 versus 11.2 days; P  < 0.001). A high sum score was associated with a shorter LOS in the total group (10.1 versus 11.2 days; P  = 0.002) and in the subgroup of community-acquired infections (9.7 versus 10.9 days; P  =   0.007), but not in the subgroup of hospital-acquired infections. We found no association between performance on QIs and in-hospital mortality or readmission rate.

Conclusions

Appropriate antibiotic use, defined by validated process QIs, in hospitalized adult patients with a suspected bacterial infection appears to be associated with a shorter LOS and therefore positively contributes to patient outcome and healthcare costs.

Impact of a pharmacist-driven care package on Staphylococcus aureus bacteremia management in a large community healthcare network: A propensity score-matched, quasi-experimental study

OBJECTIVES

Staphylococcus aureus bacteremia (SAB) is an important cause of morbidity and mortality. Suboptimal treatment has been associated with poor patient outcomes. Our antimicrobial stewardship program (ASP) evaluated SAB management based on predefined performance measures both prior to and after instituting a "care package" intervention led by clinical pharmacists and infectious diseases physicians. The primary outcome included a 4-point "optimal care score" (OCS) consisting of targeted antibiotic therapy within 24hours, repeating blood cultures, antibiotic duration assessment, and appropriate duration of therapy. The presence of an ID consult, SAB readmission and mortality were also assessed.

METHODS

This was a quasi-experimental, propensity score matched study of SAB management. Adult patients were retrospectively evaluated from October 2011 - October 2012, and intervention took place from November 2013 - December 2015. Intervention consisted of a clinical pharmacist contacting the primary team after identification of SAB to recommend (1) appropriate antibiotics within 24hours, (2) repeat blood cultures to document clearance, (3) assessment for metastatic infection, (4) and appropriate duration of therapy. These constituted the 4-point OCS. ID consult was also recommended. Patients were propensity score matched 1:2 based on age, diabetes, presence of hardware, methicillin-resistant S. aureus (MRSA) isolate, and stratified infectious source. Patients ≥18 with SAB were included.

RESULTS

Intervention was associated with improved adherence to each metric within the OCS, and more patients in the intervention cohort achieved a perfect OCS of 4. Intervention was associated with a lower rate of readmission and mortality.

CONCLUSION

A pharmacist-driven, ASP intervention on SAB therapy was associated with increased adherence to core SAB care metrics and reduced relapse and mortality.

Association of Evidence-Based Care Processes With Mortality in Staphylococcus aureus Bacteremia at Veterans Health Administration Hospitals, 2003-2014

IMPORTANCE

Staphylococcus aureus bacteremia is common and frequently associated with poor outcomes. Evidence indicates that specific care processes are associated with improved outcomes for patients with S aureus bacteremia, including appropriate antibiotic prescribing, use of echocardiography to identify endocarditis, and consultation with infectious diseases (ID) specialists. Whether use of these care processes has increased in routine care for S aureus bacteremia or whether use of these processes has led to large-scale improvements in survival is unknown.

OBJECTIVE

To examine the association of evidence-based care processes in routine care for S aureus bacteremia with mortality.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational cohort study examined all patients admitted to Veterans Health Administration (VHA) acute care hospitals who had a first episode of S aureus bacteremia from January 1, 2003, through December 31, 2014.

EXPOSURES

Use of appropriate antibiotic therapy, echocardiography, and ID consultation.

MAIN OUTCOMES AND MEASURES

Thirty-day all-cause mortality.

RESULTS

Analyses included 36 868 patients in 124 hospitals (mean [SD] age, 66.4 [12.5] years; 36 036 [97.7%] male), including 19 325 (52.4%) with infection due to methicillin-resistant S aureus and 17 543 (47.6%) with infection due to methicillin-susceptible S aureus. Risk-adjusted mortality decreased from 23.5% (95% CI, 23.3%-23.8%) in 2003 to 18.2% (95% CI, 17.9%-18.5%) in 2014. Rates of appropriate antibiotic prescribing increased from 2467 (66.4%) to 1991 (78.9%), echocardiography from 1256 (33.8%) to 1837 (72.8%), and ID consultation from 1390 (37.4%) to 1717 (68.0%). After adjustment for patient characteristics, cohort year, and other care processes, receipt of care processes was associated with lower mortality, with adjusted odds ratios of 0.74 (95% CI, 0.68-0.79) for appropriate antibiotics, 0.73 (95% CI, 0.68-0.78) for echocardiography, and 0.61 (95% CI, 0.56-0.65) for ID consultation. Mortality decreased progressively as the number of care processes that a patient received increased (adjusted odds ratio for all 3 processes compared with none, 0.33; 95% CI, 0.30-0.36). An estimated 57.3% (95% CI, 48.4%-69.9%) of the decrease in mortality between 2003 and 2014 could be attributed to increased use of these evidence-based care processes.

CONCLUSIONS AND RELEVANCE

Mortality associated with S aureus bacteremia decreased significantly in VHA hospitals, and a substantial portion of the decreasing mortality may have been attributable to increased use of evidence-based care processes. The experience in VHA hospitals demonstrates that increasing application of these care processes may improve survival among patients with S aureus bacteremia in routine health care settings.

["Choosing wisely" in infectious diseases : Overuse of antibiotics - too few vaccinations]

The "choosing wisely" recommendations of the German Society of Internal Medicine (DGIM) and its specialist societies address diagnostic and therapeutic procedures, which are of particular medical importance but applied too often or too rarely in clinical practice. The aim is to further improve treatment of patients. Important topics of overuse and insufficient treatment related to the diagnostics, therapy, prevention and exclusion of infectious diseases could be identified. These topics not only play an important role in the discipline of infectious diseases but are also relevant for other internal medical disciplines. These topics related to infectious diseases have also been integrated into the recommendations of the German Society of Gastroenterology, Digestive and Metabolic Diseases as well as the German Societies for Internal Intensive Care and Emergency Medicine, for Pneumology, for Nephrology and for Rheumatology. The pivotal issues of the recommendations are the inappropriate use of antibiotics and insufficient vaccination rates.

Impact of rapid identification of Staphylococcus aureus bloodstream infection without antimicrobial stewardship intervention on antibiotic optimization and clinical outcomes

Few studies have evaluated the clinical impact of polymerase chain reaction (PCR) for Staphylococcus aureus bloodstream infections in resource-limited settings that lack direct antimicrobial stewardship intervention. This retrospective cohort study compared patients with standard microbiological identification (n=343) to those with additional identification by (PCR) (n=130). Time to initiation of optimal therapy was similar between groups but substantially shorter in the PCR group for those infected with methicillin susceptible S. aureus (median 40.0h vs. 28.3h, P=0.001). After controlling for confounding factors including infectious diseases consultation, the PCR group had a shorter time to initiation of optimal therapy by 9.7h (95% CI 4.3-15.0h). Clinical outcomes were similar in the non-PCR and PCR groups. While time to initiation of optimal therapy was shorter in the PCR group, greater reductions may be realized through additional education, direct antimicrobial stewardship intervention, or additional clinician notification.

Optimal duration of antimicrobial therapy for uncomplicated Gram-negative bloodstream infections

PURPOSE

Optimal antimicrobial treatment duration for Gram-negative bloodstream infection (BSI) remains unclear. This retrospective cohort study examined effectiveness of short (7-10 days) and long (>10 days) courses of antimicrobial therapy for uncomplicated Gram-negative BSI.

METHODS

Hospitalized adults with uncomplicated Gram-negative BSI at Palmetto Health hospitals in Columbia SC, USA from January 1, 2010 to December 31, 2013 were identified. Multivariate Cox proportional hazards regression with propensity score adjustment was used to examine risk of treatment failure in the two groups.

RESULTS

During the study period, 117 and 294 patients received short and long courses of antimicrobial therapy for uncomplicated Gram-negative BSI, respectively. Overall, the median age was 67 years, 258 (63%) were women, 282 (69%) had urinary source of infection, and 271 (66%) had BSI due to Escherichia coli. The median duration of antimicrobial therapy was 8.5 and 13.3 days in the short and long treatment groups, respectively. After adjustment for the propensity to use a short course of therapy, risk of treatment failure was higher in patients receiving short compared to long courses of antimicrobial agents (HR 2.60, 95% CI: 1.20-5.53, p = 0.02). Other risk factors for treatment failure included liver cirrhosis (HR 5.83, 95% CI: 1.89-15.02, p = 0.004) and immune compromised status (HR 4.30, 95% CI: 1.57-10.80, p = 0.006). Definitive antimicrobial therapy with intravenous or highly bioavailable oral agents was associated with reduced risk of treatment failure (HR 0.33, 95% CI: 0.14-0.73, p = 0.006).

CONCLUSIONS

The current results support common clinical practice of 2 weeks of antimicrobial therapy for uncomplicated Gram-negative BSI.

The Model for End-stage Liver Disease (MELD) as a predictor of short-term mortality in Staphylococcus aureus bloodstream infection: A single-centre observational study

Background

Automated laboratory-based prediction models may support clinical decisions in Staphylococcus aureus bloodstream infections (BSIs), which carry a particularly high mortality. Small studies indicated that the laboratory-based Model for End-stage Liver Disease (MELD) score is a risk factor for mortality in critically ill patients with infections. For S. aureus BSIs, we therefore aimed to assess a potential association of the MELD score with mortality.

Methods

In this single-centre observational study, all consecutive patients with a first episode of methicillin-susceptible S. aureus BSI occurring between 2001 and 2013 were eligible. Relevant patient data were retrieved from our prospective in-house BSI database. We assessed the association of the MELD score at day of BSI onset (range ± two days) with 30-day all-cause mortality using uni- and multivariable logistic regression analysis.

Results

561 patients were included in the final analysis. The MELD score at BSI onset was associated with 30-day mortality in S. aureus BSIs (odds ratio per 1-point increase, 1.06; 95% confidence interval, 1.03‒1.09; P < 0.001). After adjustment for relevant patient and infection characteristics, an increased MELD score remained a predictor of 30-day mortality (adjusted odds ratio per 1-point increase, 1.05; 95% confidence interval, 1.01‒1.08; P = 0.005).

Conclusions

In our study population, the MELD score at BSI onset was an independent predictor of mortality in S. aureus BSIs. We therefore suggest to prospectively validate the MELD score as part of clinical decision support systems in inpatients with suspected or confirmed BSI.

Study on the utility of a statewide counselling programme for improving mortality outcomes of patients with Staphylococcus aureus bacteraemia in Thuringia (SUPPORT): a study protocol of a cluster-randomised crossover trial

INTRODUCTION

Staphylococcus aureus bacteraemia (SAB) is a frequent infection with high mortality rates. It requires specific diagnostic and therapeutic management such as prolonged intravenous administration of antibiotics and aggressive search for and control of infectious sources. Underestimation of disease severity frequently results in delayed or inappropriate management of patients with SAB leading to increased mortality rates. According to observational studies, patient counselling by infectious disease consultants (IDC) improves survival and reduces the length of hospital stay as well as complication rates. In many countries, IDC are available only in some tertiary hospitals. In this trial, we aim to demonstrate that the outcome of patients with SAB in small and medium size hospitals that do not employ IDC can be improved by unsolicited ID phone counselling. The SUPPORT trial will be the first cluster-randomised controlled multicentre trial addressing this question.

METHODS AND ANALYSIS

SUPPORT is a single-blinded, multicentre interventional, cluster-randomised, controlled crossover trial with a minimum of 15 centres that will include 250 patients with SAB who will receive unsolicited IDC counselling and 250 who will receive standard of care. Reporting of SAB will be conducted by an electronic real-time blood culture registry established for the German Federal state of Thuringia (ALERTSNet) or directly by participating centres in order to minimise time delay before counselling. Mortality, disease course and complications will be monitored for 90 days with 30-day all-cause mortality rates as the primary outcome. Generalised linear mixed modelling will be used to detect the difference between the intervention sequences. We expect improved outcome of patients with SAB after IDC.

ETHICS AND DISSEMINATION

We obtained ethics approval from the Ethics committee of the Jena University Hospital and from the Ethics committee of the State Chamber of Physicians of Thuringia. Results will be published in a peer-reviewed journal and additionally disseminated through public media.

TRIAL REGISTRATION NUMBER

DRKS00010135.

[Antibiotic stewardship and Staphylococcus aureus Bacteremia]

Rates of antibiotic resistance are increasing worldwide and impact on the treatment of patients with bacterial infections. A broad and uncritical application in inpatient and outpatient settings as well as in agriculture has been recognized as the main driving force. Antibiotic stewardship (ABS) programs aim at countering this worrisome development using various direct interventions such as infectious disease counseling. Blood stream infections caused by Staphylococcus (S.) aureus are severe infections associated with high mortality rates. ABS interventions such as de-eskalation of the antibiotic regimen or application of narrow-spectrum beta-lactam antibiotics can significantly reduce mortality rates. In this review, we discuss the importance of ABS programs and infectious disease counseling for the treatment of S. aureus blood stream infection.

The "Choosing Wisely" initiative in infectious diseases

OBJECTIVE

"Choosing Wisely" is a growing international campaign aiming at practice changes to improve patient health and safety by both, conduct of essential and avoidance of unnecessary diagnostic, preventive and therapeutic procedures. The goal is to create an easily recognizable and distributable list ("Choosing Wisely items") that addresses common over- and underuse in the management of infectious diseases.

METHODS

The German Society of Infectious Diseases (DGI) participates in the campaign "Klug Entscheiden" by the German Society of Internal Medicine. Committee members of the (DGI) listed potential 'Choosing Wisely items'. Topics were subjected to systematic evidence review and top ten items were selected for appropriateness. Five positive and negative recommendations were approved via individual member vote.

RESULTS

The final recommendations are: (1) Imperatively start antimicrobial treatment and remove the focus in Staphylococcus aureus bloodstream infection. (2) Critically ill patients with signs of infection need early appropriate antibiotic therapy. (3) Annual influenza vaccination should be given to individuals with age >60 years, patients with specific co-morbidities and to contact persons who may spread influenza to others. (4) All children should receive measles vaccine. (5) Prefer oral formulations of highly bioavailable antimicrobials whenever possible. (6) Avoid prescribing antibiotics for uncomplicated upper respiratory tract infections. (7) Do not treat asymptomatic bacteriuria with antibiotics. (8) Do not treat Candida detected in respiratory or gastrointestinal tract specimens. (9) Do not prolong prophylactic administration of antibiotics in patients after they have left the operating room. (10) Do not treat an elevated C-reactive protein (CRP) or procalcitonin with antibiotics for patients without signs of infection.

CONCLUSIONS

Physicians will reduce potential harm to patients and increase the value of health care when implementing these recommendations.

Characteristics of Staphylococcus aureus Bacteraemia and Predictors of Early and Late Mortality

We aimed to describe the characteristics of patients with Staphylococcus aureus bacteremia and to evaluate the risk factors associated with early (7-day) and late (30-day) mortality. We performed an observational study including all consecutive episodes of Staphylococcus aureus bacteremia diagnosed at two Italian university hospitals during 2010–2014. A total of 337 patients were included. Mean age was 69 years (range, 57–78) and 65% were males. Methicillin-resistant S. aureus (MRSA) was identified in 132/337 (39%)cases. Overall 7- and 30-day mortality were 13% and 26%, respectively. Early mortality was associated with increased Charlson scores (OR 1.3, 95% CI 1.1–1.5), MRSA bacteremia (OR 3.2, 95% CI 1.4–8.1), presentation with septic shock (OR 13.5, 95% CI 5.4–36.4), and occurrence of endocarditis (OR 4.5, 95%CI 1.4–14.6). Similar risk factors were identified for late mortality, including increased Charlson scores (OR 1.2, 95% CI 1.1–1.4), MRSA bacteremia (OR 2.1, 95% CI 1.2–3.9), presentation with septic shock (OR 4, 95%CI 1.7–9.7), occurrence of endocarditis (OR 3.8, 95% CI 1.4–10.2) as well as Child C cirrhosis (OR 3.9, 95% CI 1.1–14.4) and primary bacteremia (OR 2.5, 95%CI 1.3–5). Infectious disease consultation resulted in better outcomes both at 7 (OR 0.1, 95% CI 0.05–0.4) and at 30 days (OR 0.4, 95% CI 0.2–0.7). In conclusion, our study highlighted high rates of MRSA infection in nosocomial Staphylococcus aureus bacteremia. Multiple comorbidities, disease severity and methicillin-resistance are key factors for early and late mortality in this group. In patients with Staphylococcus aureus bacteremia, infectious disease consultation remains a valuable tool to improve clinical outcome.

Antimicrobial Stewardship: How the Microbiology Laboratory Can Right the Ship

Antimicrobial stewardship is a bundle of integrated interventions employed to optimize the use of antimicrobials in health care settings. While infectious-disease-trained physicians, with clinical pharmacists, are considered the main leaders of antimicrobial stewardship programs, clinical microbiologists can play a key role in these programs. This review is intended to provide a comprehensive discussion of the different components of antimicrobial stewardship in which microbiology laboratories and clinical microbiologists can make significant contributions, including cumulative antimicrobial susceptibility reports, enhanced culture and susceptibility reports, guidance in the preanalytic phase, rapid diagnostic test availability, provider education, and alert and surveillance systems. In reviewing this material, we emphasize how the rapid, and especially the recent, evolution of clinical microbiology has reinforced the importance of clinical microbiologists' collaboration with antimicrobial stewardship programs.

Impact of Infectious Diseases Consultation on Clinical Outcomes of Patients with Staphylococcus aureus Bacteremia in a Community Health System

Staphylococcus aureus bacteremia (SAB) causes high rates of morbidity and death. Several studies in academic health settings have demonstrated that consultations from infectious diseases specialists improve the quality of care and clinical outcomes for SAB. Few data that describe the impact in resource-limited settings such as community hospitals are available. This retrospective cohort study evaluated the adherence to quality-of-care indicators and the clinical outcomes for SAB in a five-hospital community health system (range of 95 to 272 available beds per hospital), for patients with versus without infectious diseases consultation (IDC). IDC was provided if requested by the attending physician. The primary outcome was the incidence of treatment failure, defined as 30-day in-hospital death or 90-day SAB recurrence. Other outcomes included adherence to quality-of-care indicators. A total of 473 adult patients with SAB were included, with 369 (78%) receiving IDC. We identified substantial differences in baseline characteristics between the IDC group and the no-IDC group, including greater incidences of complicated bacteremia and intravenous drug users in the IDC group, with similar rates of severe illness (measured by Pitt bacteremia scores). Adherence to quality-of-care indicators was greater for patients with IDC (P < 0.001). After adjustment for other predicting variables, IDC was associated with a lower rate of treatment failure (adjusted odds ratio, 0.42 [95% confidence interval, 0.20 to 0.86]; P = 0.018). IDC provided better quality of care and better clinical outcomes for patients with SAB who were treated at small, resource-limited, community hospitals.