Breakthrough SARS-CoV-2 infections among recipients of tixagevimab-cilgavimab prophylaxis: A citywide real-world effectiveness study

There are limited real-world data on the effectiveness of tixagevimab-cilgavimab as pre-exposure prophylaxis of COVID-19. We describe lessons learned when coordinating data collection and identifying breakthrough SARS-CoV-2 infections among patients across indications and institutions in a major US city. The Chicago Department of Public Health requested patient-level tixagevimab-cilgavimab administration data from all prescribing providers in Chicago, for treatments December 8, 2021 through June 30, 2022. Records were matched to COVID-19 vaccinations and laboratory-confirmed SARS-CoV-2 infections through December 31, 2022. Due to difficulty collecting data from all providers, targeted follow-up was conducted to improve completeness on key variables (demographics, vaccination status, clinical indication for prophylaxis). Over half of reported tixagevimab-cilgavimab administrations were to patients residing outside Chicago. Five hundred forty-four Chicago residents who received at least one dose of tixagevimab-cilgavimab were included in this analysis. Most were age 50 years or older (72%), Black non-Latinx (33%) or White non-Latinx (29%), and fully vaccinated (80%). Seventy-five patients (14%) had laboratory-confirmed COVID-19. Patients with and without breakthrough infections were demographically similar. Clinical indication was missing for >95% of cases, improved to 64% after follow-up; the most frequently specified was hematologic malignancy (10%). Severe outcomes were uncommon: 16% had documented COVID-19-related hospitalizations, one death was identified. Tixagevimab-cilgavimab recipients in Chicago had a lower rate of severe SARS-CoV-2 infection than reported among other untreated high-risk patients, including during predominance of non-neutralizing variants. Improving stakeholder collaboration is essential for generation of real-world effectiveness data, informing pandemic preparedness and optimizing use of medical countermeasures.

Using antibiotics wisely

PURPOSE OF REVIEW

This review will describe role of shorter antibiotic therapies, early switch from intravenous to oral therapy, and artificial intelligence in infectious diseases.

RECENT FINDINGS

There is evidence that shorter courses of antibiotics are noninferior to standard durations of therapy. This has been demonstrated with Enterobacterales bacteremia that can be treated with 7 days of therapy, community acquired pneumonia with 3 days and ventilator associated pneumonia with just 7 days of antibiotic therapy. The conversion from intravenous to oral therapy in treating bacteremia, endocarditis and bone and joint infections is safe and effective and reduces line complications and costs. Also, for clean surgical procedures only one dose of antibiotic is needed, but it should be the most effective antibiotic which is cefazolin. This means avoiding clindamycin, removing penicillin allergies where possible for improved outcomes. Finally, the role of artificial intelligence to incorporate into using antibiotics wisely is rapidly emerging but is still in early stages.

SUMMARY

In using antibiotics wisely, targeting such as durations of therapy and conversion from intravenous antibiotic therapy to oral are low hanging fruit. The future of artificial intelligence could automate a lot of this work and is exciting but needs to be proven.

VIDEO ABSTRACT

http://links.lww.com/COID/A50.

Implementation of a Prevention Bundle to Decrease Rates of Staphylococcus aureus Surgical Site Infection at 11 Veterans Affairs Hospitals

Importance

While current evidence has demonstrated a surgical site infection (SSI) prevention bundle consisting of preoperative Staphylococcus aureus screening, nasal and skin decolonization, and use of appropriate perioperative antibiotic based on screening results can decrease rates of SSI caused by S aureus, it is well known that interventions may need to be modified to address facility-level factors.

Objective

To assess the association between implementation of an SSI prevention bundle allowing for facility discretion regarding specific component interventions and S aureus deep incisional or organ space SSI rates.

Design, Setting, and Participants

This quality improvement study was conducted among all patients who underwent coronary artery bypass grafting, cardiac valve replacement, or total joint arthroplasty (TJA) at 11 Veterans Administration hospitals. Implementation of the bundle was on a rolling basis with the earliest implementation occurring in April 2012 and the latest implementation occurring in July 2017. Data were collected from January 2007 to March 2018 and analyzed from October 2020 to June 2023.

Interventions

Nasal screening for S aureus; nasal decolonization of S aureus carriers; chlorhexidine bathing; and appropriate perioperative antibiotic prophylaxis according to S aureus carrier status. Facility discretion regarding how to implement the bundle components was allowed.

Main Outcomes and Measures

The primary outcome was deep incisional or organ space SSI caused by S aureus. Multivariable logistic regression with generalized estimating equation (GEE) and interrupted time-series (ITS) models were used to compare SSI rates between preintervention and postintervention periods.

Results

Among 6696 cardiac surgical procedures and 16 309 TJAs, 95 S aureus deep incisional or organ space SSIs were detected (25 after cardiac operations and 70 after TJAs). While the GEE model suggested a significant association between the intervention and decreased SSI rates after TJAs (adjusted odds ratio, 0.55; 95% CI, 0.31-0.98), there was not a significant association when an ITS model was used (adjusted incidence rate ratio, 0.88; 95% CI, 0.32-2.39). No significant associations after cardiac operations were found.

Conclusions and Relevance

Although this quality improvement study suggests an association between implementation of an SSI prevention bundle and decreased S aureus deep incisional or organ space SSI rates after TJAs, it was underpowered to see a significant difference when accounting for changes over time.

Scedosporium infection disseminated "from toe to head" in allogeneic stem cell transplant recipient: a case report

BACKGROUND

Scedosporium is a lesser-known non-Aspergillus genus of mold that can present in unsuspecting ways. If overlooked, it may disseminate and cause high mortality in high-risk allogeneic stem cell transplant recipients.

CASE PRESENTATION

This case report describes a 65-year-old patient with Acute Myeloid Leukemia who underwent an allogeneic hematopoietic stem cell transplant after a period of prolonged neutropenia with fluconazole prophylaxis. She suffered severe debility with altered mentation from a S. apiospermum infection which likely disseminated from a toe wound to the lung and central nervous system. She was successfully treated with liposomal amphotericin B and voriconazole, but faced a prolonged recovery from physical and neurologic sequela.

CONCLUSIONS

The case highlights the importance of adequate anti-mold prophylaxis in high-risk patients, and the value of a thorough physical examination in this patient population, with particular attention to skin and soft tissue findings.

Eosinophilic Syndromes Associated With Daptomycin Use: Re-exposure Hypersensitivity Pneumonitis and Prior Peripheral Eosinophilia

Background

Daptomycin pulmonary eosinophilia (DPE) has been well described in case reports and reporting from the Food and Drug Administration. We report 3 eosinophilic syndromes associated with daptomycin use.

Methods

This is a retrospective review of all patients who received daptomycin (inpatient or outpatient) from 2010 to 2020 at the Veterans Affairs Portland Healthcare System. Patients who developed DPE while receiving daptomycin were evaluated to determine risk factors. Data collected included daptomycin dose and duration, body mass index, creatinine clearance, and peripheral eosinophilia.

Results

Of 330 patients who received daptomycin, 81.5% developed a peripheral eosinophilia, with 109 (33%) developing peripheral eosinophilia ≥5%. Fifty-one (16%) met criteria for DPE. Primary DPE occurred in 38 of the 51 patients with a median 26 days of treatment, and 49% had peripheral eosinophilia ≥5%. Re-exposure DPE occurred in the other 13 patients and occurred a median of 3 days after initiation of daptomycin. The presence of an elevated peripheral eosinophilia of ≥5% during daptomycin usage was significantly associated with primary (odds ratio [OR], 2.23; 95% CI, 1.2–4.09; P = .008) and re-exposure DPE (OR, 12; 95% CI, 1.6–103; P = .003). All patients recovered after withdrawal of daptomycin without complications.

Conclusions

There are 3 daptomycin eosinophilic syndromes: peripheral eosinophilia, primary DPE occurring about 4 weeks into therapy, and re-exposure DPE. Elevated peripheral eosinophilia ≥5% was a risk factor for both primary and re-exposure DPE, but still identified about half the cases. Peripheral eosinophilia should be carefully monitored during daptomycin treatment, and clinicians should be aware that prior eosinophilia may predict an acute pulmonary reaction upon daptomycin re-exposure.

Strategies for the implementation of a nasal decolonization intervention to prevent surgical site infections within the Veterans Health Administration

As part of a multicenter evidence-based intervention for surgical site infection prevention, a qualitative study was conducted with infection control teams and surgical staff members at three Department of Veterans Affairs Healthcare Systems in the USA. This study aimed to identify strategies used by nurses and other facility champions for the implementation of a nasal decolonization intervention. Site visit observations and field notes provided contextual information. Interview data were analyzed with inductive and deductive content analysis. Interview data was mapped to the Expert Recommendations for Implementing Change (ERIC) compilation of implementation strategies. These strategies were then considered in the context of power and relationships as factors that influence implementation. We found that implementation of this evidence-based surgical site infection prevention intervention was successful when nurse champions drove the day-to-day implementation. Nurse champions sustained implementation strategies through all phases of implementation. Findings also suggest that nurse champions leveraged the influence of their role as champion along with their understanding of social networks and relationships to help achieve implementation success. Nurse champions consciously used multiple overlapping and iterative implementation strategies, adapting and tailoring strategies to stakeholders and settings. Commonly used implementation categories included: "train and educate stakeholders," "use evaluative and iterative strategies," "adapt and tailor to context," and "develop stakeholder interrelationships." Future research should examine the social networks for evidence-based interventions by asking specifically about relationships and power dynamics within healthcare organizations. Implementation of evidence-based interventions should consider if the tasks expected of a nurse champion fit the level of influence or power held by the champion.

Trial registration

ClinicalTrials.gov, identifier: NCT02216227.

Non-toxigenic Vibrio cholerae in an autologous stem cell and renal transplant recipient

A patient with a renal transplant after an autologous stem cell transplant for multiple myeloma developed non-toxigenic Vibrio cholerae diarrhea after travel to Mexico. This is a rare cause of diarrhea in transplant recipients, and the patient had not had pre-travel counseling. This case reflects the lack of referral of transplant recipients for travel infectious disease review before overseas travel and the role of the live attenuated cholera vaccine.

Effect of Frequency of Changing Point-of-Use Reminder Signs on Health Care Worker Hand Hygiene Adherence: A Cluster Randomized Clinical Trial

IMPORTANCE

Although hand hygiene (HH) is considered the most effective strategy for preventing hospital-acquired infections, HH adherence rates remain poor.

OBJECTIVE

To examine whether the frequency of changing reminder signs affects HH adherence among health care workers.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized clinical trial in 9 US Department of Veterans Affairs acute care hospitals randomly assigned 58 inpatient units to 1 of 3 schedules for changing signs designed to promote HH adherence among health care workers: (1) no change; (2) weekly; and (3) monthly. Hand hygiene rates among health care workers were documented at entry and exit to patient rooms during the baseline period from October 1, 2014, to March 31, 2015, of normal signage and throughout the intervention period of June 8, 2015, to December 28, 2015. Data analyses were conducted in April 2018.

INTERVENTIONS

Hospital units were randomly assigned into 3 groups: (1) no sign changes throughout the intervention period, (2) signs changed weekly, and (3) signs changed monthly.

MAIN OUTCOMES AND MEASURES

Hand hygiene adherence as measured by covert observation. Interrupted time series analysis was used to examine changes in HH adherence from baseline through the intervention period by group.

RESULTS

Among 58 inpatient units, 19 units were assigned to the no change group, 19 units were assigned to the weekly change group, and 20 units were assigned to the monthly change group. During the baseline period, 9755 HH opportunities were observed at room entry and 10 095 HH opportunities were observed at room exit. During the intervention period, a total of 15 855 HH opportunities were observed at room entry, and 16 360 HH opportunities were observed at room exit. Overall HH adherence did not change from baseline compared with the intervention period at either room entry (4770 HH events [48.9%] vs 3057 HH events [50.1%]; P = .14) or exit (6439 HH events [63.8%] vs 4087 HH events [65.2%]; P = .06). In units that changed signs weekly, HH adherence declined from baseline at room entry (-1.9% [95% CI, -2.7% to -0.8%] per week; P < .001) and exit (-0.8% [95% CI, -1.5% to 0.1%] per week; P = .02). No significant changes in HH adherence were observed in other groups.

CONCLUSIONS AND RELEVANCE

The frequency of changing reminder signs had no effect on HH rates overall. Units assigned to change signs most frequently demonstrated worsening adherence. Considering the abundance of signs in the acute care environment, the frequency of changing signs did not appear to provide a strong enough cue by itself to promote behavioral change.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02223455.

Cryptococcosis in solid organ transplantation-Guidelines from the American Society of Transplantation Infectious Diseases Community of Practice

These updated guidelines from the Infectious Diseases Community of Practice of the American Society of Transplantation review the diagnosis, prevention, and management of cryptococcosis in the pre- and post-transplant period. The current update now includes a discussion of cryptococcosis, which is the third most common invasive fungal infection in SOT recipients. Infection often occurs a year after transplantation; however, early infections occur and donor-derived infections have been described within 3 months after transplant. There are two main species that cause infection, Cryptococcus neoformans and C gattii. Clinical onset may be insidious, but headaches, fevers, and mental status changes should warrant diagnostic testing. The lateral flow cryptococcal antigen assay is now the preferred test from serum and cerebrospinal fluid due to its rapidity, accuracy, and cost. A lumbar puncture with measurement of opening pressure is recommended for patients with suspected or proven cryptococcosis. Lipid amphotericin B plus 5-flucytosine is used as initial treatment of meningitis, disseminated infection, and moderate-to-severe pulmonary infection, followed by fluconazole as consolidation therapy. Fluconazole is effective for mild-to-moderate pulmonary infection. Immunosuppression reduction as part of management may lead to immune reconstitution syndrome that may resemble active disease.

1382. Acute Kidney Injury with Piperacillin–tazobactam and Vancomycin in the Intensive Care Unit

Background

Several recent retrospective studies have suggested that the combination of vancomycin (V) with piperacillin–tazobactam (PTZ) is associated with increased nephrotoxicity. We prospectively evaluated the outcomes of patients admitted to all of our medical and surgical intensive care units (ICU) with a normal baseline creatinine clearance (CrCl) that received vancomycin in combination with either cefepime (CEF) or PTZ to determine whether kidney injury occurs using RIFLE criteria.

Methods

ICU patients who received combinations of V with either PTZ or CEF were prospectively evaluated from June 1, 2017 to April 28, 2018 using Theradoc. V and PTZ dosing were standardized per ICU policy and monitored by clinical pharmacists. We included patients between ages 18 and 90, and receipt of &gt;72 hours of combination antibiotic therapy. We excluded patients that were pregnant, had a hematologic malignancy, chronic kidney disease, or neuromuscular disease. Data collected included, CrCl, V troughs, dosage and length of all antibiotics used, ICU length of stay (LOS), and co-administered nephrotoxic medications (e.g., NSAIDs and IV contrast). The primary objective was to compare the incidence of AKI in these study groups, as defined by the RIFLE criteria.

Results

Of 233 patients evaluated, 58 (25%) met inclusion criteria, 45 received PTZ-V and 13 CEF-V. Only eight of 58 (14%) MRSA-positive culture.

We found no correlation with co-administered nephrotoxic agents, vancomycin troughs, or body weight and AKI.

Conclusion

Our prospective observational study data revealed significant AKI with PTZ-V compared with CEF-V but it did not impact patient long-term outcomes. Caution with PTZ-V may be required when used in ICU settings even in patients with normal baseline CrCl.

Disclosures

J. S. Lewis II, Merck: Consultant, Consulting fee.

2402. Daptomycin Pulmonary Eosinophilia: Review of Cases and New Hyperacute Syndromic Presentation

Background

Daptomycin pulmonary eosinophilia (DPE) has been described as a rare event. Since the Food and Drug Administration (FDA) first described the syndrome which occurs about 3 weeks after starting the drug, it continues to be a miss diagnosed. Most outpatient antibiotic treatment (OPAT) programs focus on screening for CPK elevations. We describe an unusual increase in DPE at our center including acute reactions on re-exposure to daptomycin.

Methods

Retrospective review from local VA pharmacy and OPAT database of adverse drug events (ADE) with daptomycin from 2010 to April 2018. Data evaluated include, age, gender, weight, body mass index (BMI), daptomycin dosing, indication for use, duration of therapy, time to symptom onset, Creatinine clearance, white cell count (WCC), %eosinophilia (%eos), admission to intensive care unit (ICU), and clinical outcomes or interventions.

Results

There were 363 unique initiations of Daptomycin in the time period. There were 17 DPE (5%) and 3 CPK (0.6%) events in that time period. The medians for all DPE was; Age 68 years (range 55–95), BMI 29 m/kg² (range 21–49.5), daptomycin dose 500 mg (>7 mg/kg), baseline CrCl 35.5 mL/minute, eosinophilia at onset of DPE 9% (8–44%), and duration of therapy to onset was 21 days (1–33). All recovered on removal of daptomycin, but 5 patients required adjunctive corticosteroid therapy. Four patients had a severe and novel hyperacute DPE within 48 hours of a new initiation of daptomycin therapy. All 4 patients had prior exposure to daptomycin in the last 12 months. They presented with hypoxic respiratory failure, abnormal chest x-rays and/or CT chest scans, with preceding systemic fevers and fatigue after the first dose. All had low grade %eos (3–5%) on prior use, and all recovered rapidly with discontinuation of daptomycin.

Conclusion

DPE may be underreported and is associated with doses of 500 mg or >7 mg/kg, with CrCl <35 mL/minute and older age. Of concern are the new cases of hyperacute DPE within 48 hours of re-exposure to daptomycin that we have seen, who had prior low-grade eosinophilia. Close monitoring of these factors may be warranted in at risk individuals.

Disclosures

All authors: No reported disclosures.

2131. A Pre-operative Nursing Implemented Methicillin-resistant Staphylococcus aureus Decolonization Protocol to Decrease Surgical Site Infections

Background

Surgical site infections (SSIs) are the most common and expensive healthcare-acquired infection. Implementation of processes to prevent SSI can be difficult due to coordination of patients, providers, pharmacists, and nurses in ensuring all steps are completed before surgery. Thus, the objective of this nurse-driven process improvement project at a veterans affairs (VA) hospital, which averages 6,000 simple to complex surgeries per year, was to implement a cost-effective and practical decolonization protocol to decrease methicillin resistant Staphylococcus aureus (MRSA) SSIs across all surgical case types.

Methods

Starting May 15, 2017 a new MRSA decolonization protocol was initiated for ALL surgery cases except eye. Pre-operative clinic nurses complete MRSA nasal screening and provide detailed pre-operative showering instructions which include a focus on preventing recontamination of the skin after showers. Before surgery, nurses provide intranasal Povidone-Iodine treatment. The surgery pharmacist ensures MRSA postive patients receive pre-operative vancomycin and cefazolin if antibiotics are indicated for the surgery.

Results

For fiscal years (FY) 2012–2016 prior to protocol implementation, annual MRSA SSI rates ranged from 0.24–0.11 SSIs per 100 surgery cases; the average SSI rate for this time period 0.17. After protocol implementation there were zero MRSA SSIs in FY17 quarter 3 lowering the FY17 SSI rate to 0.09 SSIs per 100 surgery cases (see Figure 1.) Since implementation only 1 MRSA SSI has been identified making the last 4 quarter SSI rate 0.04 per 100 surgery cases (see Figure 2). This represents a 76% improvement in the 1 year MRSA SSI rate (0.04) compared with the previous 5 years MRSA SSI rate average.

Conclusion

Initial protocol results suggest that practical nursing interventions should be considered for implementation to decrease MRSA surgical site infections.

Disclosures

All authors: No reported disclosures.

795. Review of Treatment of Latent Tuberculosis Infection at VA Portland Healthcare System

Background

Treatment of latent tuberculosis infection (LTBI) is important for tuberculosis elimination in low-incidence countries. Currently, the VA Portland Health Care System (VAPORHCS) offers both 3HP (12-dose rifapentine plus isoniazid directly observed therapy (DOT)) and 9H (9-month daily isoniazid) for treatment of LTBI. Majority of veterans are treated with 9H despite increasing evidence showing higher rates of completion with 3HP. We reviewed the rates of completion and adverse events (AE) between veterans treated with 3HP and 9H.

Methods

We performed a retrospective chart review on all patients within the VAPORHCS who initiated LTBI treatment with 9H or 3HP between January 2011 and December 2016. LTBI was diagnosed through tuberculin skin testing or interferon-γ release assay. 9H treatment was self administered while 3HP was under DOT. Collected data included demographics, co-morbid conditions, immunosuppression, treatment completion, and AE. Treatment completion was determined through chart documentation.

Results

A total of 93 patients were treated for LTBI. Most patients were white (71%) and male (86%). The median age was 57 years old. Seventy-two patients (77%) were treated with 9H, and 21 (23%) were treated with 3HP. The overall completion rate was 86%. Completion rates between 9H (91%) and 3HP (86%) were not significantly different (P = 0.46). Twenty-three patients (31.9%) on 9H and six patients (28.6%) on 3HP were on chronic immunosuppression with TNF inhibitors and/or corticosteroids (P = 0.78) with an overall completion rate of 86%. Nine patients (13%) on 9H and two patients (10%) on 3HP had HIV (P = 0.95). Overall rates of AEs were similar between the groups (4%, 14%, P = 0.11), including hepatotoxicity (2%, 0%, P = 0.57) and neurotoxicity (4%, 5%, P = 0.94).

Conclusion

The overall treatment completion rates were high and statistically similar between 9H and 3HP groups, even with immunosuppressive therapy. There were no significant differences in rates of adverse events. While the majority of patients were treated with 9H, these results suggest an opportunity for more use of the 3HP, possibly without the need for DOT regimen going forward.

Disclosures

All authors: No reported disclosures.

Clinical Outcomes of the Oral Suspension vs Delayed-Release Tablet Formulations of Posaconazole for Prophylaxis of Invasive Fungal Infections

Background

Posaconazole is effective prophylaxis for invasive fungal infections (IFIs). We compared incidence of breakthrough IFI (bIFI) and early posaconazole discontinuation between patients receiving delayed-release tablet and oral suspension formulations.

Methods

This was a retrospective cohort study of patients receiving posaconazole at Oregon Health & Science University Hospital between 1/1/2010 and 6/30/2016. Oral suspension was the preferred formulation until 2/2014; afterwards the tablet was preferred. We included all courses of primary prophylaxis for each patient during the study period. Data were extracted from an electronic health record repository and via chart review. Three independent reviewers identified bIFI using European Organization for Research and Treatment of Cancer criteria. We assessed rationale for early discontinuation of posaconazole for patients that were still indicated for antifungal prophylaxis based on National Comprehensive Cancer Network (NCCN) criteria.

Results

547 patients received 859 courses of posaconazole (53% oral suspension and 48% tablet). Prophylaxis was indicated according to NCCN criteria in 91% of courses. The primary indications for prophylaxis were acute myelogenous leukemia (68%), graft-vs-host disease (18%), and myelodysplastic syndrome (3%). There were no significant differences in demographics or indication between patients receiving the different formulations. The overall incidence rate of bIFI was 4.15/10,000 posaconazole-days (16 total bIFI events). Incidence of bIFI was not significantly different between patients receiving the different formulations (P = 0.92). Posaconazole was discontinued early in 147 (17%) courses; frequency of discontinuation was not significantly different between the tablet (20%) and oral suspension (15%) formulations (P = 0.10). The primary reasons for early discontinuation were elevated liver function tests or QT prolongation (25%), inability to take an oral formulation (17%), and drug cost (17%).

Conclusion

Among patients receiving posaconazole prophylaxis, incidence of bIFI was low and not significantly different between those receiving the tablet vs oral suspension formulations.

Disclosures

J. P. Furuno, Merck & Co.: Consultant and Grant Investigator, Consulting fee, Research grant and Speaker honorarium. J. S. Lewis II, Merck & Co.: Consultant, Consulting fee. J. C. McGregor, Merck & Co.: Grant Investigator, Research grant

Feasibility of monitoring compliance to the My 5 Moments and Entry/Exit hand hygiene methods in US hospitals

We compared the ability to observe hand hygiene opportunities using the World Health Organization My 5 Moments method to the Entry/Exit method. Under covert direct observation, Entry/Exit method opportunities were observed at all times. My 5 Moments were observable in 32.3% of episodes, with a lower rate in wards versus intensive care units (28.0% vs 39.4%; P < .01). In US hospitals, the Entry/Exit method appears to be more feasible for directly observed hand hygiene compliance monitoring due to line-of-sight issues and other barriers.

Use of electronic health records and clinical decision support systems for antimicrobial stewardship

Electronic health records (EHRs) and clinical decision support systems (CDSSs) have the potential to enhance antimicrobial stewardship. Numerous EHRs and CDSSs are available and have the potential to enable all clinicians and antimicrobial stewardship programs (ASPs) to more efficiently review pharmacy, microbiology, and clinical data. Literature evaluating the impact of EHRs and CDSSs on patient outcomes is lacking, although EHRs with integrated CDSSs have demonstrated improvements in clinical and economic outcomes. Both technologies can be used to enhance existing ASPs and their implementation of core ASP strategies. Resolution of administrative, legal, and technical issues will enhance the acceptance and impact of these systems. EHR systems will increase in value when manufacturers include integrated ASP tools and CDSSs that do not require extensive commitment of information technology resources. Further research is needed to determine the true impact of current systems on ASP and the ultimate goal of improved patient outcomes through optimized antimicrobial use.

Disseminated, persistent, and fatal infection due to the vaccine strain of varicella-zoster virus in an adult following stem cell transplantation

Live attenuated varicella vaccine is recommended for healthy individuals who are susceptible to varicella. Although the vaccine is safe, effective, and used worldwide, serious adverse events have been reported, mainly in immunocompromised patients who subsequently recovered. Here, we describe the fatality of an immunocompromised patient who received the varicella vaccine. His medical history provides a cautionary lens through which to view the decision of when vaccination is appropriate. A middle-aged man with non-Hodgkin lymphoma received chemotherapy and a stem cell transplant. He was vaccinated 4 years post-transplantation, despite diagnosis of a new low-grade lymphoma confined to the lymph nodes. Within 3 months of vaccination, he developed recurrent rashes with fever, malaise, weakness, hepatitis, weight loss, and renal failure. The syndrome was eventually determined to be associated with persistent disseminated zoster caused by the vaccine virus. This case illustrates a circumstance when a live viral vaccine should not be used.

Predictors of immune reconstitution syndrome in organ transplant recipients with cryptococcosis: implications for the management of immunosuppression

BACKGROUND

Risk factors including how changes in immunosuppression influence the occurrence of immune reconstitution syndrome (IRS) in solid organ transplant (SOT) recipients with cryptococcosis have not been fully defined.

METHODS

SOT recipients with cryptococcosis were identified and followed for 12 months. IRS was defined based on previously proposed criteria.

RESULTS

Of 89 SOT recipients, 13 (14%) developed IRS. Central nervous system (CNS) disease (adjusted odds ratio [AOR], 6.23; P = .03) and discontinuation of calcineurin inhibitor (AOR, 5.11; P = .02) were independently associated with IRS. Only 2.6% (1/13) of the patients without these risk factors developed IRS compared with 18.8% (6/32) with 1 risk factor, and 50% (6/12) with both risk factors (χ(2) for trend, P = .0001). Among patients with CNS disease, those with neuroimaging abnormalities (P = .03) were more likely to develop IRS, irrespective of serum or CSF cryptococcal antigen titers and fungemia. Graft rejection after cryptococcosis was observed in 15.4% (2/13) of the patients with IRS compared with 2.6% (2/76) of those without IRS (P = .07).

CONCLUSIONS

We determined variables that pose a risk for IRS and have shown that discontinuation of calcineurin inhibitors was independently associated with 5-fold increased risk of IRS in transplant recipients with cryptococcosis.

The effect of contact precautions on healthcare worker activity in acute care hospitals

BACKGROUND AND OBJECTIVE

Contact precautions are a cornerstone of infection prevention but have also been associated with less healthcare worker (HCW) contact and adverse events. We studied how contact precautions modified HCW behavior in 4 acute care facilities.

DESIGN

Prospective cohort study.

PARTICIPANTS AND SETTING

Four acute care facilities in the United States performing active surveillance for methicillin-resistant Staphylococcus aureus.

METHODS

Trained observers performed "secret shopper" monitoring of HCW activities during routine care, using a standardized collection tool and fixed 1-hour observation periods.

RESULTS

A total of 7,743 HCW visits were observed over 1,989 hours. Patients on contact precautions had 36.4% fewer hourly HCW visits than patients not on contact precautions (2.78 vs 4.37 visits per hour; [Formula: see text]) as well as 17.7% less direct patient contact time with HCWs (13.98 vs 16.98 minutes per hour; [Formula: see text]). Patients on contact precautions tended to have fewer visitors (23.6% fewer; [Formula: see text]). HCWs were more likely to perform hand hygiene on exiting the room of a patient on contact precautions (63.2% vs 47.4% in rooms of patients not on contact precautions; [Formula: see text]).

CONCLUSION

Contact precautions were found to be associated with activities likely to reduce transmission of resistant pathogens, such as fewer visits and better hand hygiene at exit, while exposing patients on contact precautions to less HCW contact, less visitor contact, and potentially other unintended outcomes.

Antimicrobial stewardship at a large tertiary care academic medical center: cost analysis before, during, and after a 7-year program

BACKGROUND

An antimicrobial stewardship program was fully implemented at the University of Maryland Medical Center in July 2001 (beginning of fiscal year [FY] 2002). Essential to the program was an antimicrobial monitoring team (AMT) consisting of an infectious diseases-trained clinical pharmacist and a part-time infectious diseases physician that provided real-time monitoring of antimicrobial orders and active intervention and education when necessary. The program continued for 7 years and was terminated in order to use the resources to increase infectious diseases consults throughout the medical center as an alternative mode of stewardship.

DESIGN

A descriptive cost analysis before, during, and after the program.

PATIENTS/SETTING

A large tertiary care teaching medical center.

METHODS

Monitoring the utilization (dispensing) costs of the antimicrobial agents quarterly for each FY.

RESULTS

The utilization costs decreased from $44,181 per 1,000 patient-days at baseline prior to the full implementation of the program (FY 2001) to $23,933 (a 45.8% decrease) by the end of the program (FY 2008). There was a reduction of approximately $3 million within the first 3 years, much of which was the result of a decrease in the use of antifungal agents in the cancer center. After the program was discontinued at the end of FY 2008, antimicrobial costs increased from $23,933 to $31,653 per 1,000 patient-days, a 32.3% increase within 2 years that is equivalent to a $2 million increase for the medical center, mostly in the antibacterial category.

CONCLUSIONS

The antimicrobial stewardship program, using an antimicrobial monitoring team, was extremely cost effective over this 7-year period.

Community-associated methicillin-resistant Staphylococcus aureus bacteremia and endocarditis among HIV patients: a cohort study

BACKGROUND

HIV patients are at increased risk of development of infections and infection-associated poor health outcomes. We aimed to 1) assess the prevalence of USA300 community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) among HIV-infected patients with S. aureus bloodstream infections and. 2) determine risk factors for infective endocarditis and in-hospital mortality among patients in this population.

METHODS

All adult HIV-infected patients with documented S. aureus bacteremia admitted to the University of Maryland Medical Center between January 1, 2003 and December 31, 2005 were included. CA-MRSA was defined as a USA 300 MRSA isolate with the MBQBLO spa-type motif and positive for both the arginine catabolic mobile element and Panton-Valentin Leukocidin. Risk factors for S. aureus-associated infective endocarditis and mortality were determined using logistic regression to calculate odds ratios (OR) and 95% confidence intervals (CI). Potential risk factors included demographic variables, comorbid illnesses, and intravenous drug use.

RESULTS

Among 131 episodes of S. aureus bacteremia, 85 (66%) were MRSA of which 47 (54%) were CA-MRSA. Sixty-three patients (48%) developed endocarditis and 10 patients (8%) died in the hospital on the index admission Patients with CA-MRSA were significantly more likely to develop endocarditis (OR = 2.73, 95% CI = 1.30, 5.71). No other variables including comorbid conditions, current receipt of antiretroviral therapy, pre-culture severity of illness, or CD4 count were significantly associated with endocarditis and none were associated with in-hospital mortality.

CONCLUSIONS

CA-MRSA was significantly associated with an increased incidence of endocarditis in this cohort of HIV patients with MRSA bacteremia. In populations such as these, in which the prevalence of intravenous drug use and probability of endocarditis are both high, efforts must be made for early detection, which may improve treatment outcomes.

Single center experience of a vancomycin resistant enterococcal endocarditis cohort

OBJECTIVES

Vancomycin resistant enterococcus (VRE) infective endocarditis (IE) is an increasing nosocomial problem. We describe the clinical management and outcomes of a cohort of patients with VRE IE at a tertiary endocarditis referral center.

METHODS

Retrospective review of all proven cases of VRE IE, from July 2000 through January 2008 was performed. Demographics, comorbidities and therapeutic details were collected and analyzed to assess for risk factors and clinical outcomes.

RESULTS

Fifty cases of VRE IE were identified: 26 (52%) were Enterococcus faecium and 24 were Enterococcus faecalis. Vancomycin resistant E. faecalis IE was associated with the presence of a central venous line, liver transplantation, and mitral valve infection while VR E. faecium IE was significantly associated with tricuspid valve infection (p=0.03). The median duration of bacteremia was 14 days for E. faecium and 4 days for E. faecalis, respectively (p=0.002). Factors associated with mortality on bivariate analysis were hemodialysis via a catheter with VR E. faecium (OR=11.7. CI 1.1-122, p=0.02) and liver transplantation with both species. Combination antimicrobial therapy (OR=0.5 CI=0.06-3.2, p=0.1) and valve surgery (OR 1.3 CI 0.8-20, p=0.02) trended toward improved survival with E. faecalis on bivariate analysis. On multivariate analysis, none of the associations were significant.

CONCLUSIONS

Hemodialysis and liver transplantation were factors associated with acquisition of VRE IE. There was a higher mortality and prolonged bacteremia with VR E. faecium IE than VR E. faecalis IE. Although not significant, combination antimicrobial therapy and surgical intervention trended toward improved survival.

Unrecognized pretransplant and donor‐derived cryptococcal disease in organ transplant recipients

BACKGROUND

Cryptococcosis occurring ≤30 days after transplantation is an unusual event, and its characteristics are not known.

METHODS

Patients included 175 solid-organ transplant (SOT) recipients with cryptococcosis in a multicenter cohort. Very early-onset and late-onset cryptococcosis were defined as disease occurring ≤30 days or >30 days after transplantation, respectively.

RESULTS

Very early-onset disease developed in 9 (5%) of the 175 patients at a mean of 5.7 days after transplantation. Overall, 55.6% (5 of 9) of the patients with very early-onset disease versus 25.9% (43 of 166) of the patients with late-onset disease were liver transplant recipients (P = .05). Very early cases were more likely to present with disease at unusual locations, including transplanted allograft and surgical fossa/site infections (55.6% vs 7.2%; P < .001). Two very early cases with onset on day 1 after transplantation (in a liver transplant recipient with Cryptococcus isolated from the lung and a heart transplant recipient with fungemia) likely were the result of undetected pretransplant disease. An additional 5 cases involving the allograft or surgical sites were likely the result of donor&#x2010;acquired infection.

CONCLUSIONS

A subset of SOT recipients with cryptococcosis present very early after transplantation with disease that appears to occur preferentially in liver transplant recipients and involves unusual sites, such as the transplanted organ or the surgical site. These patients may have unrecognized pretransplant or donor-derived cryptococcosis.

Cutaneous cryptococcosis in solid organ transplant recipients

Clinical manifestations, treatment, and outcomes of cutaneous cryptococcosis in solid organ transplant (SOT) recipients are not fully defined. In a prospective cohort comprising 146 SOT recipients with cryptococcosis, we describe the presentation, antifungal therapy, and outcome of cutaneous cryptococcal disease. Cutaneous cryptococcosis was documented in 26/146 (17.8%) of the patients and manifested as nodular/mass (34.8%), maculopapule (30.4%), ulcer/pustule/abscess (30.4%), and cellulitis (30.4%) with 65.2% of the skin lesions occurred in the lower extremities. Localized disease developed in 30.8% (8/26), and disseminated disease in 69.2% (18/26) with involvement of the central nervous system (88.9%, 16/18), lung (33.3%, 6/18), or fungemia (55.6%, 10/18). Fluconazole (37.5%) was employed most often for localized and lipid formulations of amphotericin B (61.1%) for disseminated disease. Overall mortality at 90 days was 15.4% (4/26) with 16.7% in disseminated and 12.5% in localized disease (P = 0.78). SOT recipients who died were more likely to have renal failure (75.0% vs. 13.6%, P = 0.028), longer time to onset of disease after transplantation (87.5 vs. 22.6 months, P = 0.023), and abnormal mental status (75% vs. 13.6%, P = 0.028) than those who survived. Cutaneous cryptococcosis represents disseminated disease in most SOT recipients and preferentially involves the extremities. Outcomes with appropriate management were comparable between SOT recipients with localized and disseminated cryptococcosis.

Geographic differences in disease expression of cryptococcosis in solid organ transplant recipients in the United States

BACKGROUND

Whether there are geographic differences in clinical presentation of cryptococcosis in solid organ transplant (SOT) recipients in the United States (US) is not known.

MATERIAL/METHODS

Patients comprised a cohort of 120 SOT recipients from US transplant centers who fulfilled the EORTC/MSG criteria for cryptococcal disease.

RESULTS

Central nervous system, pulmonary, and cutaneous cryptococcal disease were observed in 51% (61/120), 64% (77/120), and 15% (18/120) of the patients, respectively. Cutaneous disease was documented in 9% (3/32) of the patients from South Atlantic region, 19% (6/32) from Mid Atlantic, 26% (6/23) from Southern, 7% (2/29) from Midwestern, and in 1 of 4 patients from the Northwestern region of the US. When controlled for age, immunosuppressive regimen, type of transplant, and renal failure at baseline, patients from the Southern compared with other regions of the US were significantly more likely to have cutaneous cryptococcal disease (OR 3.8, 95% CI 1.1-14, P=0.045).

CONCLUSIONS

Post-transplant cryptococcosis is more likely to present with cutaneous disease in the Southern region compared with other regions in the US. This predilection for cutaneous cryptococcosis could not be explained on the basis of differences in immunosuppression or the type of transplant. Whether our findings are related to strain-related variations in characteristics of the yeast or other transplant variables remains to be determined.

Outcomes with daptomycin in the treatment of Staphylococcus aureus infections with a range of vancomycin MICs

OBJECTIVES

Recent recommendations by the Infectious Diseases Society of America for the treatment of Staphylococcus aureus suggest the use of alternative agents when vancomycin MIC values are >or=2 mg/L. This study examines the outcome of patients treated with daptomycin for S. aureus infections with documented vancomycin MICs.

PATIENTS AND METHODS

All patients with skin, bacteraemia and endocarditis infections due to S. aureus with vancomycin MIC values in CORE 2005-08, a retrospective, multicentre, observational registry, were studied. The outcome (cure, improved, failure or non-evaluable) was the investigator assessment at the end of daptomycin therapy. Success was defined as cure or improved.

RESULTS

Five hundred and forty-seven clinically evaluable patients were identified with discrete vancomycin MIC values [MIC <2 mg/L: 451 (82%); MIC >or=2 mg/L: 96 (18%)]. The vancomycin MIC groups were well matched for patient characteristics, types of infections, first-line daptomycin use (19%) and prior vancomycin use (58%). Clinical success was reported in 94% of patients. No differences were detected in the daptomycin success rate by the vancomycin MIC group overall or by the infection type. A multivariate logistic regression also failed to identify vancomycin MIC as a predictor of daptomycin failure. Adverse event (AE) rates were not different when analysed by MIC group; both groups had approximately 17% of patients with one AE.

CONCLUSIONS

In this diverse population, daptomycin was associated with similar outcomes for patients, regardless of whether the vancomycin MIC was categorized as <2 or >or=2 mg/L. Further studies are warranted.

Statins in candidemia: clinical outcomes from a matched cohort study

Background

HMG CoA reductase inhibitors (statins) in patients with bacteremic sepsis have shown significant survival benefits in several studies. There is no data on the effect of statins in candidemic patients, however in-vitro models suggest that statins interfere with ergesterol formation in the wall of yeasts.

Methods

This retrospective matched- cohort study from 1/2003 to 12/2006 evaluated the effects of statins on patients with candidemia within intensive care units. Statin-users had candidemia as a cause of their systemic inflammatory response and were on statins throughout their antifungal therapy, while non-statin users were matched based on age +/- 5 years and co-morbid factors. Primary analysis was 30-day survival or discharge using bivariable comparisons. Multivariable comparisons were completed using conditional logistic regression. All variables with a p-value less than 0.10 in the bivariable comparisons were considered for inclusion in the conditional logistic model.

Results

There were 15 statin-users and 30 non-statin users that met inclusion criteria, all with similar demographics and co-morbid conditions except the statin group had more coronary artery disease (P < 0.01) and peripheral vascular disease (P = 0.03) and lower median APCAHE II scores (14.6 vs 17, p = 0.03). There were no differences in duration of candidemia, antifungal therapy or Candida species between the groups. Statins were associated with lower mortality on bivariable (OR 0.09, 95% CI 0.11-0.75, p = 0.03) and multivariable (OR 0.22, 95% CI 0.02-2.4, p = 0.21) analyses compared to controls; although, in the latter the protective effect lacked statistical signficance.

Conclusion

In our small, single-center matched-cohort study, statins may provide a survival benefit in candidemia, however further studies are warranted to validate and further explore this association.

Lipid formulations of amphotericin B significantly improve outcome in solid organ transplant recipients with central nervous system cryptococcosis

BACKGROUND

Whether outcome of central nervous system (CNS) cryptococcosis in solid organ transplant recipients treated with lipid formulations of amphotericin B is different from the outcome of the condition treated with amphotericin B deoxycholate (AmBd) is not known.

METHODS

We performed a multicenter study involving a cohort comprising consecutive solid organ transplant recipients with CNS cryptococcosis.

RESULTS

Of 75 patients treated with polyenes as induction regimens, 55 (73.3%) received lipid formulations of amphotericin B and 20 (26.7%) received AmBd. Similar proportions of patients in both groups had renal failure at baseline (P = .94 ). Overall, mortality at 90 days was 10.9% in the group that received lipid formulations of amphotericin B and 40.0% in the group that received AmBd. In univariate analysis, nonreceipt of calcineurin inhibitors (P = .034), renal failure at baseline (P = .016), and fungemia (P = .003) were significantly associated with mortality. Compared with AmBd, lipid formulations of amphotericin B were associated with a lower mortality (P = .007). Mortality did not differ between patients receiving lipid formulations of amphotericin B with or without flucytosine (P = .349). In stepwise logistic regression analysis, renal failure at baseline (odds ratio [OR], 4.61; 95% confidence interval [CI], 1.02-20.80; P = .047) and fungemia (OR, 10.66; 95% CI, 2.08-54.55; P = .004 ) were associated with an increased mortality, whereas lipid formulations of amphotericin B were associated with a lower mortality (OR, 0.11; 95% CI, 0.02-0.57; P = .008).

CONCLUSIONS

Lipid formulations of amphotericin B were independently associated with better outcome and may be considered as the first-line treatment for CNS cryptococcosis in these patients.

Lack of fluoroquinolone resistance in non-typhoidal salmonella bacteremia in HIV-infected patients in an urban US setting

Non-typhoidal salmonella (NTS) bacteremia is a significant cause of morbidity and mortality in HIV-infected individuals worldwide. Recent reports have noted increasing resistance of NTS isolates to fluoroquinolones, the recommended first-line therapy for NTS bacteremia. The outcomes and risk factors for NTS bacteremia in HIV-infected patients in an urban US setting were evaluated. From January 2002 to December 2006, 26 episodes of NTS bacteremia were identified in 16 patients. The risk factors for NTS bacteremia were low CD4 count, high viral load, and lack of antiretroviral therapy (ART). Recurrences appeared related to lack of immune reconstitution in patients not on ART. Unlike reports from Asia, no fluoroquinolone resistance was identified in any of the Salmonella strains isolated in this setting. Optimal treatment of NTS in the HIV-infected patient in the United States should include therapy with fluoroquinolones as well as attaining complete viral suppression and immune reconstitution with ART.

Mitral valve infective endocarditis: benefit of early operation and aggressive use of repair

BACKGROUND

In-hospital mortality rates for left-sided infective endocarditis (IE) exceed 20%. We investigated the outcomes of an aggressive approach to mitral valve IE that emphasizes early surgical intervention and preferential performance of mitral valve repair.

METHODS

We reviewed 89 consecutive operations in 87 patients for native mitral valve IE at a single institution from 2002 to 2007. Operations occurred promptly after completion of preoperative studies. Independent risk factors for death were investigated using multivariable logistic regression.

RESULTS

Mitral valve repair was accomplished in 56 of 89 patients (63%). Perioperative mortality was 4.4% (n = 4). Survival rates at 1 and 5 years were 89.9% (80 of 89) and 82.0% (73 of 90). There was a survival benefit for repair vs replacement at 1 (p = 0.03) and 5 years (p = 0.0017). Repair vs replacement (odds ratio [OR], 0.2; 95% confidence interval [CI], 0.06 to 0.72), diabetes (OR, 4.43; 95% CI, 1.18 to 16.66), and renal failure (OR, 3.65; 95% CI, 1.3 to 12.91) were independent risk factors for late mortality. Among 59 patients with active IE, preoperative head computed tomography (CT) showed 29 (49%) had abnormalities, including 12 (41%) with intracerebral hemorrhage. The median interval was 4 days from admission to operation. The rate of permanent postoperative stroke was 1.1% (1 of 89).

CONCLUSIONS

These results support early surgical therapy for mitral valve IE. Head CT abnormalities do not warrant delay of operation. Mitral valve repair was associated with a long-term survival advantage compared with valve replacement.

Risk factors for mortality from primary cryptococcosis in patients with HIV

Cryptococcosis continues to have a high mortality rate in human immunodeficiency virus (HIV)-positive patients despite advances made in antifungal treatment, intracranial pressure management, and antiretroviral therapy. This retrospective chart review was conducted at the University of Maryland Medical Center and Baltimore VA Medical Center from 1993 to 2004. We reviewed all inpatient cases of cryptococcal infections to assess predictors of inpatient mortality among HIV-positive patients. Data collected included patient demographics, presenting symptoms and CD4 counts, lumbar puncture (LP) results including opening pressure (OP), cryptococcal antigen (CAg) levels, sites of infection, and drug therapy. Multivariate and survival analyses were performed. We identified 202 patients with primary cryptococcosis. The main sites of infection included blood (72%), central nervous system (85%), and lower respiratory tract (34%). Overall 30-day mortality was 14%. Predictors of mortality included syncope (P = 0.039; OR, 4.5), concomitant pneumonia (P = 0.001; OR, 3.5), respiratory failure (P < 0.001; OR, 10.5), and admission into the intensive care unit (P < 0.001; OR, 8). Amphotericin dose, OP > or = 250 mm H2O, and number of LPs were not found to be predictive of mortality. Mortality attributable to cryptococcosis remains high. Our study findings suggest that syncope, respiratory failure, pneumonia, and admission to the intensive care unit are independently associated with an increased risk of death within 30 days after cryptococcosis diagnosis.

PNA FISH: present and future impact on patient management

Inappropriate and inaccurate antimicrobial therapy can lead to adverse patient outcomes and also the development of antimicrobial resistance. Peptide nucleic acid (PNA) fluorescence in situ hybridization (FISH) gives rapid reporting with highly sensitive and specific results to clinicians within 3 h after blood cultures turn positive, thereby offering targeted therapeutics where necessary. It is simple to establish compared with real-time PCR and has resulted in significant cost savings for hospitals. PNA FISH is a promising future technology for the microbiology laboratory that will impact on patient management and clinical guidelines. This article will review the clinical data supporting these new technologies.

Peptide nucleic acid fluorescent in situ hybridization for hospital-acquired enterococcal bacteremia: delivering earlier effective antimicrobial therapy

Hospital-acquired vancomycin-resistant enterococcal bacteremia has been associated with increased hospital costs, length of stay, and mortality. The peptide nucleic acid fluorescent in situ hybridization (PNA FISH) test for Enterococcus faecalis and other enterococci (EFOE) is a multicolor probe that differentiates E. faecalis from other enterococcal species within 3 h directly from blood cultures demonstrating gram-positive cocci in pairs and chains (GPCPC). A quasiexperimental study was performed over two consecutive years beginning in 2005 that identified GPCPC by conventional microbiological methods, and in 2006 PNA FISH was added with a treatment algorithm developed by the antimicrobial team (AMT). The primary outcome assessed was the time from blood culture draw to the implementation of effective antimicrobial therapy before and after PNA FISH. The severity of illness, patient location, and empirical antimicrobial therapy were measured. A total of 224 patients with hospital-acquired enterococcal bacteremia were evaluated, with 129 in the preintervention period and 95 in the PNA FISH period. PNA FISH identified E. faecalis 3 days earlier than conventional cultures (1.1 versus 4.1 days; P < 0.001). PNA FISH identified Enterococcus faecium a median 2.3 days earlier (1.1 versus 3.4 days; P < 0.001) and was associated with statistically significant reductions in the time to initiating effective therapy (1.3 versus 3.1 days; P < 0.001) and decreased 30-day mortality (26% versus 45%; P = 0.04). The EFOE PNA FISH test in conjunction with an AMT treatment algorithm resulted in earlier initiation of appropriate empirical antimicrobial therapy for patients with hospital-acquired E. faecium bacteremia.

Community-acquired methicillin-resistant Staphylococcus aureus endomyocardial abscesses in a heart transplant recipient

Infective endocarditis is more common in heart transplant recipients than in the general population. We report a case of endomyocardial abscesses and sepsis syndrome due to community-acquired methicillin-resistant Staphylococcus aureus (MRSA) in a heart transplant recipient with a negative transesophageal echocardiogram. The suspected portal of entry for this MRSA infection was through infected herpes zoster lesions. This case demonstrates the difficulty of diagnosing endomyocardial abscesses in heart transplant patients.

Rhodotorula glutinis fungemia in a liver–kidney transplant patient

A 54-year-old man underwent simultaneous liver-kidney transplantation. During his prolonged hospitalization, he developed catheter-related fungemia with Rhodotorula glutinis and azole-resistant Candida glabrata. Management of the Rhodotorula fungemia was complicated by his renal insufficiency, hepatic insufficiency, and the concurrent fungemia with multi-azole resistant C. glabrata. He was treated with combination therapy with voriconazole and micafungin with subsequent clearance of the fungemia. Rhodotorula species are emerging as human pathogens with the increasing number of immunosuppressed patients in the last few decades. This is the first report of a R. glutinis fungemia in a solid organ transplant recipient.

Clinical Experience with Daptomycin for the Treatment of Patients with Documented Gram-Positive Septic Arthritis

Background:

Septic arthritis is considered a rheumatologic emergency that can lead lo joint destruction and tong-term impairment of joint function, Daptomycin is bactericidal in vitro against Staphylococcus aureus, the primary pathogen associated with septic arthritis.

Objective:

To describe the use of daptomycin in patients with septic arthritis,

Methods:

Data were collected as part of the Cubicin Outcomes Registry and Experience (CORE) program, a retrospective, observational, multicenter study, to describe the clinical use of daptomycin. Efficacy at the end of daptomycin therapy was determined by each center's investigator(s) as cure, improved, failure, or nonevaluable. Patients who had a diagnosis of septic arthritis, excluding concomitant osteomyelitis, as well as a positive culture by needle aspirate or deep tissue biopsy, were selected from the combined 2005 and 2006 CORE database.

Results:

Twenty-two patients were included in this analysis. S. aureus was the most common pathogen isolated, with the majority resistant lo methicillin. All patients received an antibiotic prior to daptomycin; in 7 patients, at least one of the prior antibiotics was continued with daptomycin. Almost two-thirds of patients received an antibiotic with daptomycin; rifampin was the most common. The median final dose and duration of daptomycin therapy were S mg/kg (range 3–6.3) and 22 days (range 3–52), respectively. Eighty-two percent of patients received daptomycin while admitted to a hospital; however, 68% received at least part ol their daptomycin therapy as an outpatient. The outcomes of cure or improved were reported in 41% and 50% of the patients, respectively. Two adverse events were reported; neither was considered to be related to daptomycin.

Conclusions:

Daptomycin appeared to be effective when used as part of a treatment regimen for septic arthritis. These results require verification via a prospective clinical trial.

Outcomes of invasive zygomycosis infections in renal transplant recipients

Zygomycosis is an infrequent and difficult-to-treat fungal infection that is found in patients with underlying immunocompromised states. The advent of the lipid amphotericin B products has allowed for treatment with higher doses of therapy and less systemic toxicity. We reviewed the outcomes of 6 renal transplant recipients diagnosed with biopsy-proven invasive zygomycosis who received amphotericin B lipid complex (ABLC) in doses greater than 5 mg/kg between 2000 and 2004. All 6 patients had baseline diabetes mellitus, were receiving immunosuppressive agents, and subsequently underwent concomitant surgery. Three of the 6 patients that survived had undergone significant surgical debridement, reduction of their immunosuppression to minimal prednisone, and received prolonged course of ABLC at 10 mg/kg/day. All survivors lost graft function during the course of their therapy. The 3 patients who died all had delays in diagnosis of their disease and subsequent surgical and appropriate medical therapy. Therefore, in renal transplant recipients the early diagnosis of invasive zygomycosis is imperative along with early therapy with surgical debridement, reduced immunosuppression, and the use of high doses of ABLC.

Polymyxin antibiotics for gram-negative infections

PURPOSE

The role of polymyxin antibiotics in the treatment of multidrug-resistant gram-negative infections is reviewed.

SUMMARY

Antimicrobial resistance is an increasing problem across hospitals worldwide, especially in intensive care settings, where nosocomial infections are 5-10 times more likely to occur than on the general wards. The polymyxins, a group of basic polypeptide antibiotics, were first isolated from Bacillus species in the late 1940s and appear to have a surface detergent effect, making them active against most gram-negative organisms. Early clinical reports suggested a high rate of toxicity associated with the polymyxins, specifically nephrotoxicity (20%) and neurotoxicity (7%); thus the polymyxins had largely fallen out of favor. However, recent studies have suggested that the toxicities associated with the polymyxins may be less severe and less frequent than earlier reports. The emergence of multidrug-resistant gram-negative organisms has led to a reemergence in the use of this antibiotic class. Various clinical trials that evaluated the polymyxins for the treatment of multidrug-resistant gram-negative organisms found that these antibiotics have acceptable effectiveness and may be used if necessary.

CONCLUSION

The polymyxins have become a last resort for the treatment of infections caused by multidrug-resistant gram-negative organisms. Recent studies have suggested that the frequency of polymyxin-associated nephrotoxicity and neurotoxicity may not be as high as was once thought. The polymyxins seem to be effective in treating various infections caused by multidrug-resistant gram-negative organisms but should not be used as first-line therapy until more is known about this class of antibiotics.