Respiratory culture nudge improves antibiotic prescribing for Moraxella catarrhalis and Haemophilus influenzae lower respiratory tract infections

A decade of clinical microbiology: top 10 advances in 10 years: what every infection preventionist and antimicrobial steward should know

The past 10 years have brought paradigm-shifting changes to clinical microbiology. This paper explores the top 10 transformative innovations across the diagnostic spectrum, including not only state of the art technologies but also preanalytic and post-analytic advances. Clinical decision support tools have reshaped testing practices, curbing unnecessary tests. Innovations like broad-range polymerase chain reaction and metagenomic sequencing, whole genome sequencing, multiplex molecular panels, rapid phenotypic susceptibility testing, and matrix-assisted laser desorption ionization time-of-flight mass spectrometry have all expanded our diagnostic armamentarium. Rapid home-based testing has made diagnostic testing more accessible than ever. Enhancements to clinician-laboratory interfaces allow for automated stewardship interventions and education. Laboratory restructuring and consolidation efforts are reshaping the field of microbiology, presenting both opportunities and challenges for the future of clinical microbiology laboratories. Here, we review key innovations of the last decade.

What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research

Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.

Leveraging stewardship to promote ceftriaxone use in severe infections with low- and no-risk AmpC Enterobacterales

AmpC β-lactamases are associated with development of ceftriaxone resistance despite initial in vitro susceptibility, but the risk of AmpC derepression is not equal among Enterobacterales. The purpose of this study was to evaluate the impact of an AmpC stewardship intervention on the definitive treatment of low- and no-risk Enterobacterales. This was an IRB-approved, single pre-test, post-test quasi-experiment at a 5-hospital system. An AmpC stewardship intervention was implemented in July 2022 and included prescriber education, the removal of microbiology comments indicating potential for ceftriaxone resistance on therapy, and the modification of a blood PCR comment for Serratia marcescens to recommend ceftriaxone. Adults ≥18 years pre-intervention (July 2021 to December 2021) and post-intervention (July 2022 to December 2022) who received ≥72 hours of inpatient definitive therapy and had non-urine cultures growing low- and no-risk organisms (S. marcescens, Providencia spp., Citrobacter koseri, Citrobacter amalonaticus, or Morganella morganii) were included. The primary endpoint was definitive treatment with ceftriaxone. A total of 224 patients were included; 115 (51%) in pre-intervention and 109 (49%) in post-intervention. Definitive ceftriaxone therapy was prescribed more frequently after intervention [6 (5%) vs 72 (66%), P < 0.001]. After adjustment for critical illness, patients in the post-group were more likely to receive definitive ceftriaxone (adjOR, 34.7; 95% CI, 13.9-86.6). The proportion of patients requiring retreatment was 18 (15%) and 11 (10%) for pre- and post-intervention patients (P = 0.22), and ceftriaxone resistance within 30 days occurred in 5 (4%) and 2 (2%) patients in the pre- and post-group (P = 0.45). An antimicrobial stewardship intervention was associated with increased ceftriaxone prescribing and similar patient outcomes for low- and no-risk AmpC Enterobacterales.

Aminopenicillins versus Non-aminopenicillins for Treatment of Enterococcal Lower Urinary Tract Infections

Aminopenicillins achieve urinary concentrations that exceed typical minimum inhibitory concentrations for enterococcal lower urinary tract infection (UTI). Our clinical microbiology laboratory discontinued routine susceptibilities on enterococcal urine isolates and reports "aminopenicillins are predictably reliable for uncomplicated enterococcal UTI". The study objective was to compare outcomes of aminopenicillins (AP) to non-aminopenicillins (NAP) for enterococcal lower UTIs. This was an IRB approved, retrospective cohort of adults hospitalized with symptomatic enterococcal lower UTIs from 2013-2021. Primary endpoint: composite clinical success at 14-days, defined as resolution of symptoms without new symptoms and no repeat culture growth of index organism. A non-inferiority analysis was utilized with a 15% margin, and logistic regression evaluated characteristics associated with 14-day failure. 178 subjects were included: 89 AP, 89 NAP. VRE was identified in 73 (82%) AP and 76 (85%) NAP patients (P=0.54); a total of 34 (38.2%) AP and 66 (74.2%) NAP patients had confirmed E. faecium (P<0.001). Amoxicillin (36, 40.5%) and ampicillin (36, 40.5%) were the most frequent AP utilized; linezolid (41, 46%) and fosfomycin (30, 34%) were the most frequent NAP. 14-day clinical success for AP and NAP was 83.1% and 82.0% (1.1% difference, 97.5%CI, -0.117-0.139). Among the E. faecium subgroup, 14-day clinical success was observed in 27/34 (79.4%) of AP and 53/66 (80.3%) of NAP patients (P=0.916). In logistic regression, APs were not associated with 14-day clinical failure (adjOR 0.84; 95%CI, 0.38-1.86). Aminopenicillins were noninferior to non-aminopenicillins for treating enterococcal lower UTIs and may be considered irrespective of susceptibility results.