Evaluating the efficacy and safety of letermovir compared to valganciclovir for the prevention of human cytomegalovirus disease in adult lung transplant recipients

BACKGROUND

Lung transplant recipients are at high risk for severe cytomegalovirus (CMV) disease. Off-label use of letermovir (LET) may avert myelotoxicity associated with valganciclovir (VGCV), but data in lung transplantation are limited. This study aims to evaluate the outcomes of LET prophylaxis among lung transplant recipients.

METHODS

This retrospective, matched cohort study included lung transplant recipients who received LET for primary CMV prophylaxis following VGCV intolerance. Patients were matched 1:1 to historical VGCV controls based on age, serostatus group, and time from transplant. The primary outcome was CMV breakthrough within 1 year post-LET initiation; secondary outcomes included hematologic changes.

RESULTS

A total of 124 lung transplant recipients were included per group (32% CMV mismatch, D+R-), with LET initiated a median of 9.6 months post-transplantation. One CMV breakthrough event (0.8%) was observed in the LET group versus four (3.2%) in the VGCV group (p = .370). The median (interquartile range) white blood cell (WBC) count was 3.1 (2.1-5.6) at LET initiation which increased to 5.1 (3.9-7.2) at the end of follow-up (p <.001). For VGCV controls, WBC was 4.8 (3.4-7.2) at baseline and 5.4 (3.6-7.2) at the end of follow-up; this difference was not statistically significant (p = .395). Additionally, 98.4% of LET patients experienced ≥1 leukopenia episode in the year prior to LET compared to 71.8% the year after initiation (p <.001). Similar results were observed for neutropenia (48.4% and 17.7%, p <.001).

CONCLUSION

LET prophylaxis was associated with a low rate of CMV reactivation and leukopenia recovery. LET may represent a reasonable prophylaxis option for lung transplant recipients unable to tolerate VGCV.

Effect of letermovir initiation on tacrolimus concentrations among lung transplant recipients receiving concomitant azole antifungal prophylaxis

BACKGROUND

The antiviral letermovir has been increasingly used as off-label cytomegalovirus prophylaxis in solid organ transplant recipients. Observational studies have reported notable increases in tacrolimus (FK) exposure following letermovir; however, whether a significant interaction occurs in the setting of existing moderate-to-strong CYP3A4 inhibition is unknown. Therefore, the purpose of this study was to evaluate FK trough changes before and after letermovir among lung transplant recipients receiving azole antifungal prophylaxis.

METHODS

This retrospective cohort study included lung transplant recipients newly initiated on letermovir between 2019-2022 following valganciclovir intolerance. Tacrolimus doses and concentrations were collected up to 30 days before and after the letermovir start date. No pre-emptive FK dose adjustments occurred prior to letermovir initiation. Patients admitted to the hospital or lacking an appropriately timed trough in the pre- or post-period were excluded.

RESULTS

A total of 78 lung transplant recipients receiving FK (1.5 mg median total daily dose) and itraconazole (56.4%), isavuconazole (25.6%) or posaconazole (17.9%) prophylaxis were included. Letermovir was started at a median of 8.4 months post-transplant. The pre-/post-letermovir median FK trough was 9.6/9.0 ng/mL (p = .151), median dose-corrected trough was 4.2/4.7 ng/mL/mg (+11.9%, p = .032), and median weight-based dose-corrected trough was 362/326 [ng/mL]/[mg/kg/day] (-9.9%, p = .036). There was no significant difference in the proportion of patients within their goal trough range before and after letermovir initiation (62% vs. 72%, p = .229).

CONCLUSION

Empiric FK dose adjustments do not appear warranted before letermovir initiation in lung transplant recipients receiving antifungal prophylaxis with moderate-to-strong CYP3A4 inhibitors.

Early Experiences with Intrathecal Administration of Amphotericin B Liposomal Formulation at a Neurosurgical Center

BACKGROUND

Intrathecal administration of amphotericin B represents an important adjunctive therapy for management of severe fungal meningitis. Intrathecal preparations have traditionally used amphotericin B deoxycholate. Liposomal amphotericin B is an alternative formulation with good clinical outcomes as systemic therapy, but scant data exist investigating intrathecal use.

OBJECTIVE

The aim of this exploratory study was to evaluate outcomes following intrathecal administration of liposomal amphotericin B for treatment of severe fungal meningitis.

METHODS

A national shortage of amphotericin B deoxycholate necessitated revision of institutional protocols at a southwestern neurosurgical center in Spring 2023. A starting intrathecal daily dose of 0.125-0.5 mg liposomal amphotericin B was recommended (dependent on insertion device), with 0.125-0.25 mg slow titration every 48 h and up to a 2 mg maximum daily dose.

RESULTS

Four cases of fungal meningitis treated with adjunctive intrathecal amphotericin B liposomal formulation were reviewed. This included three cases of coccidioidal meningitis and one case of presumed Fusarium solani meningitis following an outbreak. All patients had initial disease improvement following initiation of intrathecal amphotericin B and were able to tolerate long-term therapy. One coccidioidal meningitis patient expired of neurologic complications shortly after being moved from the intensive care unit (ICU) to a floor unit. All other patients were successfully discharged from the hospital. New headache was the only reported adverse effect, which was managed with dose reduction and did not require therapy discontinuation.

CONCLUSIONS

Liposomal amphotericin B may be feasibly administered intrathecally for the adjunctive treatment of severe fungal meningitis.

Doxycycline versus cephalexin treatment of presumed streptococcal skin and soft tissue infection among adults presenting to the emergency department

Among 100 propensity score-matched emergency department patients receiving ≤14 days doxycycline versus cephalexin monotherapy for outpatient treatment of nonpurulent (presumed streptococcal) skin and soft tissue infection, a low rate of 14-day clinical failure was observed [6% each group; odds ratio (OR), 1.34 (0.21-8.69); P = 0.745], defined as hospital admission, i.v. antibiotic therapy, or change in oral antibiotic. Doxycycline may represent a reasonable therapeutic alternative for this indication in regions with low tetracycline resistance.

Trimethoprim-sulfamethoxazole significantly reduces the risk of nocardiosis in solid organ transplant recipients: systematic review and individual patient data meta-analysis

BACKGROUND

Whether trimethoprim-sulfamethoxazole (TMP-SMX) prophylaxis prevents nocardiosis in solid organ transplant (SOT) recipients is controversial.

OBJECTIVES

To assess the effect of TMP-SMX in the prevention of nocardiosis after SOT, its dose-response relationship, its effect on preventing disseminated nocardiosis, and the risk of TMP-SMX resistance in case of breakthrough infection.

METHODS

A systematic review and individual patient data meta-analysis.

DATA SOURCES

MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Web of Science Core Collection, and Scopus up to 19 September 2023.

STUDY ELIGIBILITY CRITERIA

(a) Risk of nocardiosis between SOT recipients with and without TMP-SMX prophylaxis, or (b) sufficient details to determine the rate of TMP-SMX resistance in breakthrough nocardiosis.

PARTICIPANTS

SOT recipients.

INTERVENTION

TMP-SMX prophylaxis versus no prophylaxis.

ASSESSMENT OF RISK OF BIAS

Risk Of Bias In Non-randomized Studies-of Exposure (ROBINS-E) for comparative studies; dedicated tool for non-comparative studies.

METHODS OF DATA SYNTHESIS

For our primary outcome (i.e. to determine the effect of TMP-SMX on the risk of nocardiosis), a one-step mixed-effects regression model was used to estimate the association between the outcome and the exposure. Univariate and multivariable unconditional regression models were used to adjust for the potential confounding effects. Certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

RESULTS

Individual data from three case-control studies were obtained (260 SOT recipients with nocardiosis and 519 uninfected controls). TMP-SMX prophylaxis was independently associated with a significantly decreased risk of nocardiosis (adjusted OR = 0.3, 95% CI 0.18-0.52, moderate certainty of evidence). Variables independently associated with an increased risk of nocardiosis were older age, current use of corticosteroids, high calcineurin inhibitor concentration, recent acute rejection, lower lymphocyte count, and heart transplant. Breakthrough infections (66/260, 25%) were generally susceptible to TMP-SMX (pooled proportion 98%, 95% CI 92-100).

CONCLUSIONS

In SOT recipients, TMP-SMX prophylaxis likely reduces the risk of nocardiosis. Resistance appears uncommon in case of breakthrough infection.

Can fluconazole be used for inpatient re-treatment of coccidioidomycosis among patients with past fluconazole exposures?

BACKGROUND

Coccidioides spp. may cause significant disease requiring hospitalisation, but optimal antifungal therapy among inpatients following outpatient fluconazole exposures is unknown.

OBJECTIVES

The objective of this study is to describe the effectiveness of fluconazole among patients hospitalised for coccidioidomycosis despite recent outpatient fluconazole treatment.

PATIENTS/METHODS

Patients were admitted to an academic medical center in Phoenix, Arizona from 1 January 2013 through 31 December 2020 for coccidioidomycosis following at least 30 days of outpatient treatment and re-initiation of fluconazole upon admission. The primary outcome was the proportion of patients with an improved response per the change in the modified Mycosis Study Group (MSG) score (a composite of symptoms, serology and radiographic findings) and clinician impressions.

RESULTS

Sixty-seven patients were included, with most (54%) admitted to the intensive care unit. Meningitis was the most common infectious presentation (55%), 17 patients (25%) had multiple infection sites, and 23 (34%) were culture-positive for Coccidioides. Upon admission, the median (IQR) MSG score was 11 (9-14), which dropped to 4 (1-7) at end of therapy or last follow-up. Overall, after initiation of fluconazole therapy at a median daily dose of 800 mg, 48 patients (72%) improved in overall status, 10 (15%) showed stable disease and 9 (13%) were unresponsive. Improved response rates were high across all infection sites, including meningitis (68%) and bone infection (71%). There was no significant difference in response rates between patients with and without reported outpatient fluconazole nonadherence.

CONCLUSIONS

The majority of patients admitted to the hospital for coccidioidomycosis appeared responsive to fluconazole therapy despite past outpatient exposures.

Adherence and outcomes of a surgical prophylaxis guideline promoting cephalosporin use among patients with penicillin allergy

BACKGROUND

The study purpose was to assess adherence to a local surgical prophylaxis guideline in patients with reported penicillin allergies, which recommends cephalosporins as first-line prophylaxis.

METHODS

Adult patients with penicillin allergies admitted for a surgical procedure from July 2020 to June 2021 were retrospectively screened, and the first surgery per admission was included. The primary outcome was the proportion of surgeries using β-lactam prophylaxis. Additional outcomes included prophylaxis timing, hypersensitivity reactions, acute kidney injury, infectious complications, duration of stay, and 30-day mortality or readmission.

RESULTS

Among 597 procedures, 504 patients (84.4%) received a β-lactam for surgical prophylaxis, including 494 (82.3%) who received a cephalosporin. Patients in the non-β-lactam group were more likely to have a type I IgE-mediated penicillin allergy (48.4% vs 31.7%, P = .002); however, the majority with type I reactions still received β-lactams (78.0%), including in the setting of anaphylaxis or angioedema to penicillin (67.7%). Zero allergic reactions to prophylaxis antibiotics were reported in either group, and there were no significant differences in the proportion of patients receiving drugs associated with the management of allergic reactions. Receipt of non-β-lactams was associated with inappropriate prophylaxis timing (9.7% vs 3.2%, P = .005) and postprocedural acute kidney injury (7.5% vs 0.6%, P < .001). All other outcomes were nonsignificant between the groups.

CONCLUSION

Among surgical patients with a documented penicillin allergy, most received cephalosporin prophylaxis as recommended by institutional guidelines, with zero allergic reactions. Receipt of non-β-lactam prophylaxis was associated with worsened outcomes. Cephalosporin prophylaxis should be preferred for surgical patients, including in the setting of true penicillin allergy.

Universal Lifelong Fungal Prophylaxis and Risk of Coccidioidomycosis in Lung Transplant Recipients Living in an Endemic Area

BACKGROUND

Lung transplant recipients residing in the endemic region are vulnerable to severe morbidity and mortality from Coccidioides. As infection risk persists beyond the first posttransplant year, investigations evaluating extended prophylaxis durations are needed. The purpose of this study is to assess the incidence of coccidioidomycosis among lung transplant recipients receiving universal lifelong azole antifungal prophylaxis.

METHODS

Patients receiving transplants from 2013-2018 and initiated on azole antifungal prophylaxis at a lung transplant center in Arizona were included and followed through 2019 or until death, second transplant, or loss to follow-up. Recipients who died or received treatment for coccidioidomycosis during the transplant admission, or who had received a previous transplant, were excluded. The primary outcome was proven or probable coccidioidomycosis with new asymptomatic seropositivity assessed secondarily.

RESULTS

A total of 493 lung transplant recipients were included, with 82% initiated on itraconazole prophylaxis, 9.3% on voriconazole, and 8.5% on posaconazole. Mean age at transplant was 62 years, 77% were diabetic, and 8% were seropositive for Coccidioides pretransplant. After a median follow-up of 31 months, 1 proven infection and 1 case of new asymptomatic seropositivity (1/493 each, 0.2% incidence) occurred during the study period. The single coccidioidomycosis case occurred 5 years posttransplant in a patient who had azole prophylaxis stopped several months prior. Although within-class switches were common throughout the study period, permanent discontinuation of azole prophylaxis was rare (1.4% at end of follow-up).

CONCLUSIONS

Universal lifelong azole prophylaxis was associated with a low rate of coccidioidomycosis among lung transplant recipients residing in endemic regions.

Impact of the COVID-19 Pandemic on the Emotional Intelligence of Student Pharmacist Leaders

Objective. To assess changes in Emotional Intelligence Appraisal (EIA) scores following the COVID-19 pandemic for pharmacy students within a voluntary cocurricular leadership development program.Methods. Participants from the class of 2021 (pandemic group) completed an EIA self-assessment near the beginning of the leadership program in August 2019 (pre-pandemic) and at the end of the program in July 2020 (during peak first-wave COVID-19 activity) and wrote an accompanying self-reflection. To determine changes in students' emotional intelligence potentially attributable to COVID-19, differences in EIA scores from the pandemic group were compared to the pooled results of previous program cohorts (classes of 2017-2019). Prevalent themes in student self-reflections were also highlighted.Results. Thirty-five student leaders comprised the pandemic group, with 166 students included within the control group. The proportion of students with final EIA scores indicating high emotional intelligence was greater within the pandemic group (74.3% vs 50.6%). While both groups had increased final EIA scores compared to baseline values, score increases were significantly higher among students in the pandemic group with respect to overall emotional intelligence and relationship management. Students commented that the pandemic highlighted the importance of emotional intelligence during stressful situations, although the lack of in-person interaction was noted as a limitation for social development.Conclusion. Pharmacy students participating in a leadership development program during the COVID-19 pandemic experienced greater increases in emotional intelligence than did the program's pre-pandemic cohorts. This may support the ability of health professional students to maintain resiliency through the pandemic and develop both personal and interpersonal relationship-building skills.

Unexplained mortality during the US COVID-19 pandemic: retrospective analysis of death certificate data and critical assessment of excess death calculations

OBJECTIVES

Cause-of-death discrepancies are common in respiratory illness-related mortality. A standard epidemiological metric, excess all-cause death, is unaffected by these discrepancies but provides no actionable policy information when increased all-cause mortality is unexplained by reported specific causes. To assess the contribution of unexplained mortality to the excess death metric, we parsed excess deaths in the COVID-19 pandemic into changes in explained versus unexplained (unreported or unspecified) causes.

DESIGN

Retrospective repeated cross-sectional analysis, US death certificate data for six influenza seasons beginning October 2014, comparing population-adjusted historical benchmarks from the previous two, three and five seasons with 2019-2020.

SETTING

48 of 50 states with complete data.

PARTICIPANTS

16.3 million deaths in 312 weeks, reported in categories-all causes, top eight natural causes and respiratory causes including COVID-19.

OUTCOME MEASURES

Change in population-adjusted counts of deaths from seasonal benchmarks to 2019-2020, from all causes (ie, total excess deaths) and from explained versus unexplained causes, reported for the season overall and for time periods defined a priori: pandemic awareness (19 January through 28 March); initial pandemic peak (29 March through 30 May) and pandemic post-peak (31 May through 26 September).

RESULTS

Depending on seasonal benchmark, 287 957-306 267 excess deaths occurred through September 2020: 179 903 (58.7%-62.5%) attributed to COVID-19; 44 022-49 311 (15.2%-16.1%) to other reported causes; 64 032-77 054 (22.2%-25.2%) unexplained (unspecified or unreported cause). Unexplained deaths constituted 65.2%-72.5% of excess deaths from 19 January to 28 March and 14.1%-16.1% from 29 March through 30 May.

CONCLUSIONS

Unexplained mortality contributed substantially to US pandemic period excess deaths. Onset of unexplained mortality in February 2020 coincided with previously reported increases in psychotropic use, suggesting possible psychiatric or injurious causes. Because underlying causes of unexplained deaths may vary by group or region, results suggest excess death calculations provide limited actionable information, supporting previous calls for improved cause-of-death data to support evidence-based policy.

Outcomes of nontuberculous mycobacteria isolation among lung transplant recipients: A matched case-control with retrospective cohort study

DISCLAIMER

In an effort to expedite the publication of articles , AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Lung transplant recipients are at increased risk for acquiring nontuberculous mycobacteria (NTM), but the clinical significance of NTM isolation, particularly among patients not meeting guideline-endorsed diagnostic criteria for NTM pulmonary disease, is unclear.

METHODS

A case-control study of lung transplant recipients with culture-positive NTM infections treated at a large transplant center during a 7-year period (2013-2019) was performed.

RESULTS

Twenty-nine cases were matched 1:2 to non-NTM controls. The median time to NTM isolation was 10.7 months post transplant. Only 34.5% of all cases, and half of treated cases, met diagnostic criteria for NTM pulmonary infection. All-cause mortality at 12 months was numerically higher among NTM cases versus controls (20.7% vs 8.6%, P = 0.169); however, no deaths were attributed to NTM. No increase in the 12-month rate of acute rejection was observed (27.6% vs 36.2%, P = 0.477). Recent augmented immunosuppression was associated with increased odds of NTM isolation, while azithromycin prophylaxis was associated with reduced odds of isolation and was not associated with macrolide resistance. Both adverse events and actual or potential drug-drug interactions occurred in more than 90% of treated cases; these events included ocular toxicity, hearing loss, and supratherapeutic calcineurin inhibitor concentrations. Eight of the 14 treated cases (57.1%) required early antibiotic discontinuation due to adverse events or drug-drug interactions.

CONCLUSION

Among lung transplant recipients, most patients with NTM isolation did not meet guideline criteria for infection and had outcomes similar to non‒NTM-infected patients, which may reflect transient lung colonization by NTM rather than true disease. As adverse events are common with NTM therapy, limiting unnecessary antibiotic treatment represents an area for future antimicrobial stewardship efforts.

Impact of the FilmArray meningitis/encephalitis panel on antimicrobial duration among patients with suspected central nervous system infection

Ten controlled studies evaluated antimicrobial use following implementation of the FilmArray meningitis and encephalitis panel versus usual care. Only one-half of studies identified significant reductions in antibiotic duration, with 8/10 reporting modest reductions for acyclovir. Coupling the FilmArray meningitis and encephalitis panel with interventions by antimicrobial stewardship programs may help enhance its clinical impact.

Enhancing the Emotional Intelligence of Student Leaders Within an Accelerated Pharmacy Program

Objective. To determine student pharmacists' perceptions of a leadership development program for student organization officers and report the changes in their Emotional Intelligence Appraisal (EIA) scores.Methods. Between 2015-2018, three different cohorts of Doctor of Pharmacy students participated in a voluntary leadership development program that spanned six academic quarters. The program included a variety of self-assessments and large-group topic discussions, followed by quarterly individual written reflections with feedback from faculty mentors. These activities primarily addressed the topics of emotional intelligence, strengths-based leadership, and continuous leadership development. Participants' EIA scores near the beginning and end of the program were compared. An anonymous online survey of participant perceptions was administered at the end of the program.Results. One hundred sixty-six student pharmacists completed all program activities. Each cohort's final mean overall, self-awareness, self-management, and social awareness EIA scores were higher than their corresponding mean initial scores. The overall response rate for the online survey was 61%. All respondents either strongly agreed or agreed that participating in the program enhanced their leadership skills. The majority of respondents additionally rated each of the program's activities as being either beneficial or very beneficial. The emotional intelligence assessment and strengths-based leadership assessment were the activities that were most frequently cited as being very beneficial.Conclusion. The pilot implementation of this leadership development program appears to have been both impactful and well received. Programs structured like this one may provide an effective way of increasing the emotional intelligence of student pharmacists, particularly within accelerated pharmacy programs.

Patient perspectives of pharmacists prescribing HIV pre-exposure prophylaxis: A survey of patients receiving antiretroviral therapy

BACKGROUND

Groundbreaking new laws granting community pharmacists the authority to prescribe human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP) medications have the potential to substantially expand PrEP access in high-risk communities. However, whether patients will be accepting of pharmacists as PrEP providers is underexplored within the literature.

OBJECTIVES

To assess patient perspectives of pharmacist PrEP prescribing and identify potential barriers to acceptance of pharmacist-prescribed PrEP.

METHODS

Adult patients currently receiving antiretroviral therapy for HIV prophylaxis or treatment at a specialty pharmacy were surveyed telephonically from January 2020-April 2020. A 4-point Likert scale was used to measure perceptions in addition to open-ended questions.

RESULTS

The participation rate was 87.5%. Of the 49 included patients, 100% agreed/strongly agreed that pharmacists were knowledgeable about medications, but they were less likely to strongly agree that pharmacists were knowledgeable about HIV drugs (14.3% vs. 75.5% for other drugs, P < 0.001). Most (93.9%) of the patients agreed/strongly agreed that they would feel comfortable seeking a pharmacist for PrEP information or HIV testing. With respect to PrEP prescribing, 16.3% disagreed that they would feel comfortable having a pharmacist prescribe their first fill of PrEP, preferring to speak to their physician or expressing concerns that pharmacists have inadequate training. All patients expressed a desire for additional HIV/PrEP training requirements for pharmacists before allowing them to prescribe PrEP. A portion of the respondents (18.4%) expressed concerns that the increased availability of PrEP would lead to persons becoming lax about barrier protection. However, 100% of the patients agreed/strongly agreed that having pharmacist-prescribed PrEP would benefit their community.

CONCLUSION

Patients receiving antiretroviral therapy reported overall favorable perceptions of pharmacist PrEP prescribing; however, some concerns relating to pharmacists' level of training in HIV exist. This may be ameliorated through increased pharmacist education, including how to counsel patients seeking PrEP on behavioral risk reduction.

COVID-19 in a lung transplant recipient: Exploring the diagnostic role of circulating exosomes and the clinical impact of advanced immunosuppression

Exosomes isolated from plasma of lung transplant recipients with allograft injury contain donor‐derived lung self‐antigens (collagen V and Kα1 tubulin) and human leukocyte antigen (HLA) molecules. We present a case of a 76‐year‐old, female lung transplant recipient treated for acute cellular rejection with methylprednisolone and anti‐thymocyte globulin, who subsequently contracted SARS‐CoV‐2 and developed a sharp increase in the mean fluorescent intensity of anti‐HLA antibodies. Analysis of circulating exosomes during rejection, but before SARS‐CoV‐2 infection, revealed the presence of lung self‐antigens and HLA class II molecules. After the patient contracted SARS‐CoV‐2, exosomes with the SARS‐CoV‐2 spike protein were also found. After resolution of infectious symptoms, exosomes with SARS‐CoV‐2 spike protein were no longer detected; however, exosomes with lung self‐antigens and HLA class II molecules persisted, which coincided with a progressive decline in spirometric flows, suggesting chronic lung allograft dysfunction. We propose that the analysis of circulating exosomes may be used to detect allograft injury mediated by both rejection and infection. Furthermore, the detection of exosomes containing viral proteins may be helpful in identifying allograft injury driven by viral pathogens.

Nocardia prophylaxis, treatment, and outcomes of infection in lung transplant recipients: A matched case-control study

BACKGROUND

Lung transplant recipients are at heightened risk for nocardiosis compared to other solid organ transplant recipients, with incidence rates as high as 9% and up to 30% associated mortality. No controlled studies assessing risk factors for nocardiosis in this high-risk population have been reported.

METHODS

Patients undergoing lung transplantation at a single center between 2012 and 2018 and diagnosed with nocardiosis post-transplant were matched 1:2 to uninfected control subjects on the basis of age, transplant date, and sex.

RESULTS

The incidence of nocardiosis in this lung transplant population was 3.4% (20/586), occurring a median of 9.4 months (range 4.4-55.2) post-transplant. In multivariable analysis, consistent use of trimethoprim/sulfamethoxazole (TMP/SMX) in the 12 weeks prior to diagnosis was independently associated with protection against nocardiosis (OR 0.038; 95% CI 0.01-0.29; P = .002). Augmented immunosuppression in the 6 months prior to diagnosis was independently associated with the development of nocardiosis (OR 9.94; 95% CI 1.62- 61.00; P = .013). Six case patients (30%) had disseminated disease; all-cause 6-month mortality was 25%. The most common species was Nocardia farcinica (7/17 isolates), which was associated with dissemination and mortality. The most active antibiotics were TMP/SMX (100%), linezolid (100%), and amikacin (76%). Imipenem was only active against 4/17 isolates (24% susceptibility), with two isolates becoming non-susceptible later in therapy.

CONCLUSIONS

Trimethoprim/sulfamethoxazole prophylaxis was shown to be protective against nocardiosis in lung transplant recipients, while augmented immunosuppression conferred increased risk. Institutional epidemiologic data are needed to best guide empiric therapy for Nocardia, as historical in vitro data may not predict local susceptibilities.

Prevalence and dental professional awareness of antibiotic self-medication among older adults: Implications for dental education

OBJECTIVE

Antibiotic stewardship has been recognized as an essential component of dental education. A notable threat to stewardship is the growing trend toward self-medication with nonprescribed antibiotics (SMNPA), particularly among older adults who may be at increased risk for adverse outcomes. This study aimed to assess the need to incorporate SMNPA into dental education by researching (1) professional awareness and (2) self-medication behaviors among older adults.

METHODS

A SMNPA awareness survey was administered to dentists in Arizona with 148 respondents including general dentists, dental school faculty, and public health clinicians. A second survey was distributed to 410 households in an independent and assisted living facility.

RESULTS

The dentists were aware of sources of SMNPA such as friends/family, leftover prescriptions, as well as sources outside of the United States; however, most (>80%) were not aware that ornamental fish antibiotics could be obtained online or in pet stores. The survey response rate for the older adults was 46.3%, of which 68.3% reported antibiotic use within the past 2 years (several for dental premedication) and 6.4% (n = 12) admitted to SMNPA for treating cold symptoms or pain. The main reason given for self-treatment was the belief that antibiotics had resolved similar symptoms in the past. One-third of the older adult respondents were unaware that antibiotics only treat bacterial infections.

CONCLUSION

Approximately 1 in 16 older adults surveyed reported SMNPA. Dental professionals reported some knowledge of SMNPA but were unaware of all sources. This study highlights the need for SMNPA education, awareness, and implementation within dental curricula.

Low Sensitivity of Procalcitonin for Bacteremia at an Academic Medical Center: A Cautionary Tale for Antimicrobial Stewardship

Background

Procalcitonin testing has been adopted by antimicrobial stewardship programs as a means of reducing inappropriate antibiotic use, including within intensive care units (ICUs). However, concerns regarding procalcitonin's sensitivity exist. The purpose of this study is to calculate the sensitivity of procalcitonin for bacteremia among hospitalized patients.

Methods

This was a retrospective cohort study of adult patients admitted to an academic medical center between July 1, 2018, and June 30, 2019, with ≥1 positive blood culture within 24 hours of admission and procalcitonin testing within 48 hours. Low procalcitonin was defined as <0.5 µg/L.

Results

A total of 332 patients were included. The sensitivity of procalcitonin for bacteremia was 62% at the sepsis threshold of 0.5 µg/L, 76% at a threshold of 0.25 µg/L, and 92% at a threshold of 0.1 µg/L. Of the 125 patients with low procalcitonin, 14% were initially admitted to the ICU and 9% required the use of vasopressors. In that same group, the top 3 organisms isolated were Staphylococcus aureus (39%), Escherichia coli (17%), and Klebsiella spp. (7%). Compared with those patients with elevated procalcitonin, patients with low procalcitonin were significantly more likely to have >24-hour delayed receipt of antibiotic therapy (3% vs 8%; P = .04), including among patients admitted to the ICU (1% vs 18%; P = .02).

Conclusions

The sensitivity of procalcitonin for bacteremia is unacceptably low for a rule-out test. Antimicrobial stewardship programs should use caution before promoting the withholding of antibiotic therapy for patients with low initial procalcitonin values.

A case report of self-medication with over-the-counter fish antibiotic: Implications for pharmacists

OBJECTIVE

The human use of over-the-counter antibiotics intended for the treatment of pet animals has been recognized as a potential barrier to antibiotic stewardship efforts. The objective of this report is to describe a case of self-medication with a fish antibiotic resulting in delayed medical treatment and provide recommendations for pharmacists practicing in outpatient settings on how to best identify and manage nonprescription antibiotic use.

CASE SUMMARY

A 24-year-old man experienced dental pain and "flu-like" symptoms for which he attempted self-treatment with oral amoxicillin 250 mg daily purchased by a family member from a pet store. The amoxicillin was marketed for the treatment of bacterial infection in pet fish. After several days of increasing tooth pain despite the self-medication, the patient presented to an outpatient clinic where he was found to have a molar abscess requiring tooth extraction. The patient responded well to therapy and was counseled to discontinue antibiotic self-treatment.

PRACTICE IMPLICATIONS

Undocumented use of nonprescription antibiotics represents a threat to patient safety. Potential deleterious outcomes include resistance, adverse drug events, and delays in definitive infection treatment. Pharmacists should screen patients for nonprescription antibiotic use, provide them counseling on appropriate antibiotic use, and educate other health care professionals on underrecognized sources of nonprescription antibiotics to increase awareness of this growing issue. Furthermore, antibiotic resistance should be considered when recommending an antibiotic agent for the treatment of infections.

Association of Antibiotic Treatment Duration With Recurrence of Uncomplicated Urinary Tract Infection in Pediatric Patients

Background: Gaps and inconsistencies in published information about optimal antibiotic treatment duration for uncomplicated urinary tract infection (UTI) in pediatric patients pose a dilemma for antibiotic stewardship. Objective: Evaluate the association of antibiotic treatment duration with recurrence rates in children with new-onset cystitis or pyelonephritis. Methods: Retrospective cohort analysis of patients aged 2 to 17 years with new-onset cystitis or pyelonephritis and without renal/anatomical abnormality was conducted using Truven Health MarketScan Database for 2013-2015. Results: Of 7698 patients, 85.5% had cystitis, 14.3% pyelonephritis. Duration of antibiotic treatment was as follows: 3 to 5 days for cystitis (20.4%) or 7 (33.6%), 10 (44.2%), or 14 (1.8%) days for any UTI. Recurrence occurred in 5.5% of patients. Covariates associated with increased recurrence risk included pretreatment antibiotic exposure (odds ratio [OR] = 1.29; 95% CI = 1.06-1.57), pyelonephritis on diagnosis date (OR = 1.44; 95% CI = 1.03-2.00), follow-up visit during antibiotic treatment (OR = 3.21; 95% CI = 2.20-4.68), parenteral antibiotic (OR = 1.89; 95% CI = 1.33-2.69), and interaction of pyelonephritis diagnosis with nitrofurantoin monotherapy (OR = 3.68; 95% CI = 1.20-11.29). After adjustment for covariates, the association between duration of antibiotic treatment and recurrence was not significant (compared with 7 days: 10 days: OR = 1.07, 95% CI = 0.85-1.33; 14 days: OR = 0.89, 95% CI = 0.45-1.78). Conclusions and Relevance: Antibiotic treatment duration was not significantly associated with recurrence of uncomplicated UTI in a national pediatric cohort. Results provide support for shorter-course treatment, consistent with antimicrobial stewardship efforts.

Adverse Events Associated With Antibiotics and Intravenous Therapies for Post-Lyme Disease Syndrome in a Commercially Insured Sample

Background

Non-guideline-endorsed posttreatment courses of antibiotics for post-Lyme disease syndrome (PLDS) have been linked to adverse patient outcomes, but these findings have yet to be validated in large systematic evaluations.

Methods

A retrospective cohort analysis of medical and pharmacy claims derived from the Truven Health Market Scan Commercial Claims and Encounters Database assessed 90-day incidence rates of adverse events (AEs) associated with PLDS treatment (PLDS-Tx). Patients were diagnosed with PLDS ≥6 months after initial diagnosis and standard antibiotic treatment for Lyme disease. Comparison cohorts included intravenous (IV) PLDS-Tx with or without oral antibiotics; oral antibiotic-only PLDS-Tx; or neither.

Results

Composite AE incidence rates were higher for patients treated with IV or oral PLDS-Tx than for patients not receiving either treatment (18.7%, 16.8%, and 13.4%, respectively; P = .019). Significant between-group differences in AE incidence rates were noted for electrolyte imbalance (4.0%, 1.5%, and 0.7%, respectively; P = .001) and infection (14.0%, 12.7%, and 9.3%; P = .006). Infection prevalence increased by 22.0% in the IV treatment group and 17.7% in the oral group. Incidence rates for all-cause and AE-related hospital stays and emergency department visits were higher for treated than nontreated patients, particularly when treatment was IV (all P < .01). Of IV-treated patients, 7.3% experienced an incident all-cause inpatient stay and 11.3% an incident all-cause emergency department visit, compared with, respectively, 2.2% and 3.4% of those treated with oral antibiotics and 0.9% and 1.9% of nontreated patients.

Conclusions

Use of IV therapies or oral antibiotics for PLDS was associated with increased patient morbidity within 90 days.

Estimated Cardiovascular Risk and Guideline-Concordant Primary Prevention With Statins: Retrospective Cross-Sectional Analyses of US Ambulatory Visits Using Competing Algorithms

INTRODUCTION

The 2013 pooled cohort equations (PCE) may misestimate cardiovascular event (CVE) risk, particularly for black patients. Alternatives to the original PCE (O-PCE) to assess potential statin benefit for primary prevention-a revised PCE (R-PCE) and US Preventive Services Task Force (USPSTF) algorithms-have not been compared in contemporary US patients in routine office-based practice.

METHODS

We performed retrospective, cross-sectional analysis of a nationally representative, US sample of office visits made from 2011 to 2014. Sampling criteria matched those used for PCE development: aged 40 to 79 years, black or white race, no cardiovascular disease. Original PCE, R-PCE, and USPSTF algorithms were applied to biometric and demographic data. Outcomes included estimated 10-year CVE risk, percentage exceeding each algorithm's statin-treatment threshold (>7.5% risk for O-PCE and R-PCE, and >10% O-PCE plus >1 risk factor for USPSTF), and percentage prescribed statin therapy.

RESULTS

In 12 556 visits (representing 285 330 123 nationwide), 10.8% of patients were black, 27.1% had diabetes, and 15.7% were current smokers. Replacing O-PCE with R-PCE decreased mean (95% confidence interval [CI]) estimated CVE risk from 12.4% (12.0%-12.7%) to 8.5% (8.2%-8.8%). Significant (P < 0.05) racial disparity in the rate of CVE risk >7.5% was identified using O-PCE (black and white patients [95% CI], respectively: 58.8% [54.6%-62.9%] vs 52.8% [51.1%-54.4%], P = .006) but not R-PCE (41.6% [37.6%-45.7%] vs 39.9% [38.3%-41.5%], P = .448). Revised PCE and USPSTF recommendations were concordant for 90% of patients. Significant racial disparity in guideline-concordant statin prescribing was found using O-PCE (black and white patients, respectively, 35.0% [30.5%-39.9%] vs 41.8% [39.9%-44.4%], P = .013), but not R-PCE (40.6% [35.0%-46.6%] vs 43.0% [40.0%-45.9%], P = .482) or USPSTF recommendations (39.0% [33.8%-44.5%] vs 44.4% [41.5%-47.5%], P = .073).

CONCLUSIONS

Use of an alternative to O-PCE may reduce racial disparity in estimated CVE risk and may facilitate shared decision-making about primary prevention.

Emergence of letermovir resistance in a lung transplant recipient with ganciclovir-resistant cytomegalovirus infection

Following a year of valganciclovir prophylaxis, a lung transplant recipient developed cytomegalovirus (CMV) infection that became resistant to ganciclovir, as confirmed by detection of UL97 kinase mutation M460V and a previously uncharacterized UL54 DNA polymerase mutation L516P. The latter mutation is now shown to confer ganciclovir and cidofovir resistance. As predicted from the viral genotype, foscarnet therapy was effective, but resumption of valganciclovir as secondary prophylaxis resulted in a plasma viral load rebound to 3.6 log₁₀ copies/mL several weeks later. Valganciclovir was then replaced by letermovir, resulting in gradual viral load reduction in the first 5 weeks to below the quantitation limit (2.7 log₁₀ copies/mL) for 1 week, followed by 10 weeks of rising viral loads reaching 4.3 log₁₀ copies/mL while on letermovir. At this point, CMV genotypic testing revealed UL56 mutation C325Y, which confers absolute resistance to letermovir. Retreatment with foscarnet was successful. This case adds to the considerable list of proven ganciclovir resistance mutations, and provides an early experience with letermovir resistance after off-label therapeutic use. This experience is consistent with in vitro observations of rapid emergence of letermovir-resistant CMV after drug exposure.

1506. Association of Antibiotic Treatment Duration with First Recurrence of Uncomplicated Urinary Tract Infection in Pediatric Patients

Background

The optimal antibiotic (ABX) treatment duration for uncomplicated urinary tract infection (UTI) in pediatric patients is unknown. The objective of this study was to investigate the association of pediatric UTI treatment duration (7, 10, or 14 days) with infection recurrence or progression.

Methods

A retrospective cohort analysis of pediatric patients aged 2–17 years with first cystitis or pyelonephritis and without renal/anatomic abnormality was performed using claims and eligibility data from Truven Health MarketScan Database for 2013–2015. Parenteral ABX use and treatment of cystitis diagnosis only were covariates. Relapse and reinfection were defined a priori as UTI diagnosed from, respectively, 0–14 days and 15–30 days following ABX depletion; recurrence was defined as either relapse or reinfection. Progressing infection was defined as recurrence diagnosis of pyelonephritis in a patient originally diagnosed with cystitis only.

Results

Of 7,698 pediatric patients (43.8% aged 2–10 years; 56.2% aged 11–17 years), 85.5% had cystitis and 14.3% pyelonephritis. Duration of ABX treatment included: 3–5 days for cystitis only (20.4%), or 7 (33.6%), 10 (44.2%), or 14 (1.8%) days for any UTI. Recurrence and progressing infection occurred in 5.5% and 0.2% of patients, respectively. Covariates associated with increased recurrence risk included pre-treatment ABX exposure (OR = 1.29; 95% CI = 1.06–1.57); pyelonephritis on diagnosis date (OR = 1.44; 95% CI = 1.03–2.00); follow-up visit during ABX treatment (OR = 3.21; 95% CI = 2.20–4.68); parenteral ABX (OR = 1.89, 95% CI = 1.33–2.69); use of nitrofurantoin (NFT) only (OR = 1.34, 95% CI = 1.00–1.92); and interaction of NFT with pyelonephritis diagnosis (OR = 3.68, 95% CI = 1.20–11.29). After adjustment for measured confounders, the association between duration of ABX treatment and recurrence was not significant (compared with 7 days, 10 days: OR = 1.07, 95% CI = 0.85–1.33; compared with 7 days, 14 days: OR = 0.89, 95% CI 0.45–1.78).

Conclusion

In a national cohort of pediatric patients with uncomplicated UTI, rates of recurrence after ABX depletion did not significantly differ among treatment durations of 7, 10, and 14 days. Results provide support for, without definitively establishing efficacy of, shorter-course ABX treatment.

Disclosures

All authors: No reported disclosures.

Successful Lung Re-transplant in a Patient with Cepacia Syndrome due to Burkholderia ambifaria

Chronic airway inflammation and infection drive morbidity and mortality among patients with cystic fibrosis (CF). While Haemophilus influenzae and Staphylococcus aureus predominate in children, the prevalence of Pseudomonas aeruginosa increases as patients age. Other bacteria, including species within the Burkholderia cepacia complex (Bcc), are also more prevalent among adults with CF. Species within the Bcc accelerate lung function decline and can trigger development of "cepacia syndrome," both before and after lung transplantation. As a result, some centers advise against lung transplantation for Bcc-infected patients; however, little is known about the relative virulence of uncommon Bcc species. We describe a successful lung re-transplant in a patient with CF, chronic Burkholderia ambifaria airway infection, and cepacia syndrome.

Pharmacotherapy-Induced Hepatitis B Reactivation Among Patients With Prior Functional Cure: A Systematic Review

OBJECTIVE

To describe and quantify the incidence and morbidity of hepatitis B reactivation (HBVr) secondary to pharmaceutical agents (eg, rituximab, tumor necrosis factor inhibitors, direct-acting antivirals [DAAs] for hepatitis C) among patients with previously resolved hepatitis B infection.

DATA SOURCES

The MEDLINE database was searched from inception through July 2018 using the terms hepatitis B + ( reactivation OR [drug or drug class linked to HBVr]).

STUDY SELECTION AND DATA EXTRACTION

Relevant English-language cohort studies or randomized trials quantifying the incidence of HBVr secondary to pharmacotherapy among patients negative for hepatitis B surface antigen and DNA and positive for hepatitis B core antibody were included.

DATA SYNTHESIS

Among 2045 articles, 102 met inclusion criteria. Receipt of rituximab was associated with the highest risk of HBVr (for oncological indication: 6.2% rate [225/3601 patients]) and subsequent hepatitis (up to 52.4% of all HBVr cases). Biologic agents for autoimmune disease were uncommonly associated with HBVr (2.4%, 56/2338), with only 4 cases of hepatitis, all attributable to rituximab. Reactivation caused by DAAs was rare (0.3%, 28/8398), with no cases of hepatitis. Relevance to Patient Care/Clinical Practice: This review compares and contrasts the incidence and clinical relevance of HBVr for various pharmacotherapies among patients with functionally cured hepatitis B, with discussion of appropriate risk mitigation strategies.

CONCLUSIONS

Among patients with prior functional cure of hepatitis B, prophylactic antiviral therapy is recommended with rituximab administration irrespective of indication because of a high risk for HBVr-associated morbidity. Enhanced monitoring alone is reasonable for patients receiving nonrituximab biologics or DAAs.

Optimizing skin and skin structure infection outcomes: considerations of cost of care

INTRODUCTION

Skin and skin structure infections (SSSIs) refer to a collection of clinical infectious syndromes involving layers of skin and associated soft tissues. Although associated with less morbidity and mortality than other common skin infections, SSSIs represent a significant increasing source of healthcare expense, with a prevalence of 500 episodes per 10,000 patient-years in the United States resulting in burdening health care systems, of approximately $6 billion annually.

AREAS COVERED

Opportunities to reduce costs of care associated with SSSI are highlighted, including transitions of care and avoiding unnecessary hospital admissions. Moreover, we reviewed new antibiotics (e.g. single dose glycopeptides), and the impact of consulting specialists in the emergency department on SSSI treatment outcomes.

EXPERT COMMENTARY

New healthcare models and payment strategies combined with new therapeutics are challenging norms of care. Newer drugs to treat skin infections can move a substantive percent of patients previously admitted to hospital care to the outpatient setting. Additionally, patients can be managed with oral or one time intravenous regimens, improving the likelihood of patient adherence and satisfaction. These variables need to be weighed against added acquisition costs and the development of thoughtful algorithms is needed to direct care and optimize treatment, cost, and patient satisfaction.

Necessity of carbapenem use when prescribed per infectious diseases specialists

Preauthorization strategies, including restricting broad-spectrum antimicrobials such as carbapenems to infectious diseases physicians (ID) are commonly employed by stewardship programs. The appropriateness, or "necessity" of empiric carbapenem therapy by ID, defined as an isolated organism sensitive to the carbapenem and resistant to cefepime, was evaluated over a 6month span and included 84 patients. Additionally, 30 patients followed by ID who were not prescribed a carbapenem until final susceptibilities were included as a definitive therapy group. Differences in multi-drug resistant organism (MDRO) risk factors between groups were non-significant. Carbapenem therapy was necessary for only 6 (7%) empiric therapy patients, while four times as many definitive group patients required a carbapenem but did not receive one empirically. Overall, ID's ability to accurately gauge which patients required carbapenems appeared poor in this study. Alternative risk stratification strategies may better guide broad-spectrum antimicrobial use than ID judgment alone.

Ceftolozane/tazobactam and ceftazidime/avibactam for the treatment of complicated intra-abdominal infections

Complicated intra-abdominal infections (cIAI) represent a large proportion of all hospital admissions and are a major cause of morbidity and mortality in the intensive care unit. Rising rates of multidrug resistant organisms (MDRO), including extended-spectrum β-lactamase producing Enterobacteriaceae and carbapenem-nonsusceptible Pseudomonas spp., for which there are few remaining active antimicrobial agents, pose an increased challenge to clinicians. Patients with frequent exposures to the health care system or multiple recurrent IAIs are at increased risk for MDRO; however, treatment options have traditionally been limited, in some cases necessitating the utilization of last-line agents with unfavorable side-effect profiles. Ceftolozane/tazobactam and ceftazidime/avibactam are two new cephalosporin and β-lactamase inhibitor combinations with recent US Food and Drug Administration approvals for the treatment of cIAI in combination with metronidazole. Ceftolozane/tazobactam has demonstrated excellent in vitro activity against MDR and extensively drug-resistant Pseudomonas spp., including carbapenem-nonsusceptible strains, while ceftazidime/avibactam effectively inhibits a broad range of β-lactamases, making it an excellent option for the treatment of carbapenem-resistant Enterobacteriaceae. Both agents were shown to be noninferior to meropenem for treatment of cIAI in Phase III trials; however, reduced responses in patients with renal impairment at baseline highlight the importance of routine serum creatinine monitoring and ongoing dose adjustments. This review highlights in vitro and in vivo data of these two agents and suggests their proper place in cIAI treatment to ensure adequate therapy in our most at-risk patients while sparing unnecessary use in patients without MDRO risk factors.