Antibiotic Myths for the Infectious Diseases Clinician

Antimicrobials are commonly prescribed and often misunderstood. With more than 50% of hospitalized patients receiving an antimicrobial agent at any point in time, judicious and optimal use of these drugs is paramount to advancing patient care. This narrative will focus on myths relevant to nuanced consultation from infectious diseases specialists, particularly surrounding specific considerations for a variety of antibiotics.

Evaluation of an Opt-Out Protocol for Antibiotic De-Escalation in Patients With Suspected Sepsis: A Multicenter, Randomized, Controlled Trial

BACKGROUND

Sepsis guidelines recommend daily review to de-escalate or stop antibiotics in appropriate patients. This randomized, controlled trial evaluated an opt-out protocol to decrease unnecessary antibiotics in patients with suspected sepsis.

METHODS

We evaluated non-intensive care adults on broad-spectrum antibiotics despite negative blood cultures at 10 US hospitals from September 2018 through May 2020. A 23-item safety check excluded patients with ongoing signs of systemic infection, concerning or inadequate microbiologic data, or high-risk conditions. Eligible patients were randomized to the opt-out protocol vs usual care. Primary outcome was post-enrollment antibacterial days of therapy (DOT). Clinicians caring for intervention patients were contacted to encourage antibiotic discontinuation using opt-out language. If continued, clinicians discussed the rationale for continuing antibiotics and de-escalation plans. To evaluate those with zero post-enrollment DOT, hurdle models provided 2 measures: odds ratio of antibiotic continuation and ratio of mean DOT among those who continued antibiotics.

RESULTS

Among 9606 patients screened, 767 (8%) were enrolled. Intervention patients had 32% lower odds of antibiotic continuation (79% vs 84%; odds ratio, 0.68; 95% confidence interval [CI], .47-.98). DOT among those who continued antibiotics were similar (ratio of means, 1.06; 95% CI, .88-1.26). Fewer intervention patients were exposed to extended-spectrum antibiotics (36% vs 44%). Common reasons for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was unsafe (31%). Thirty-day safety events were similar.

CONCLUSIONS

An antibiotic opt-out protocol that targeted patients with suspected sepsis resulted in more antibiotic discontinuations, similar DOT when antibiotics were continued, and no evidence of harm.

CLINICAL TRIALS REGISTRATION

NCT03517007.

1798. Impact and Sustainability of Antibiotic Prescribing Feedback with Peer Comparison to Hospitalists in a Community Hospital

Background

Antibiotic prescribing feedback with peer comparison has been shown to reduce antibiotic prescription rates in the outpatient setting, but data regarding its impact in community hospitals are lacking. We previously developed novel denominator metrics to control for differences between physician practices such as patient volume or workload. Using these metrics, we provided regular antibiotic prescribing feedback with peer comparison to hospitalists in a community hospital over four years and evaluated its impact on targeted antibiotic prescribing.

Methods

Antibiotic days of therapy (DOT) for all antibacterials and targeted agents (aztreonam, antipseudomonal beta-lactams, vancomycin, and the fluoroquinolones (FQ)) were obtained from electronic medication administration records and linked to the ordering hospitalist. Physician-specific shifts worked data by month were calculated from local administrative datasets. De-identified data were presented in DOT/shifts worked, and trends in facility-wide and hospitalist-specific antibiotic prescribing were evaluated.

Results

A total of 37,938 antibiotic DOTs were prescribed by hospitalists from January 2018 to March 2022. De-identified feedback was shared in-person (4/2018, 4/2019, 3/2020, 11/2021) or virtually (9/2020) in small group sessions, and education, including local antibiogram data and recommended alternatives, was provided for targeted agents. Of the 31 hospitalists that received feedback, trends in FQ use for 7 hospitalists with longitudinal data are shown (Figure 1). In the month following feedback sessions, hospitalist antibiotic use data demonstrated substantial reductions in FQ prescribing, and similar trends were observed among all targeted agents. A single hospitalist’s prescribing trend for targeted agents is shown in Figure 2. Facility-wide, targeted agent use decreased 31% from 2017 to 2021 and was primarily driven by reductions in use by hospitalists.

Conclusion

Regular antibiotic prescribing feedback with peer comparison and education was associated with a reduction in targeted agent prescribing by hospitalists at a community hospital.

Disclosures

All Authors: No reported disclosures.

935. Antibiotic Use (AU) Adjustment by Infection-Related Patient Volume Across a Health System

Background

Benchmarking AU is important to identify opportunities and allocate resources within a health system. Patient level factors such as infection diagnosis codes further refine risk adjustments but have not been more widely adopted because of the burden of accurately collecting and submitting granular data. The goal of this study was to evaluate a novel metric to estimate facility-level infection burden as a potential factor to use in adjustment of AU.

Methods

We conducted a retrospective analysis of hospital administrative data (for calendar year 2020) from 8 hospitals in a single health system using a common electronic health record and coding department. We identified inpatient encounters with an infection-related primary ICD-10 code (I-PDX), based on the health system’s coding department determination and extracted the length of stay (LOS) for each encounter. For any encounter with an I-PDX, the entire LOS was classified as infection-related patient days (IPD). Overall AU in days of therapy (DOT) was adjusted using two novel infection diagnoses denominators. The first was based on proportion of total patient days (PD) attributable to I-PDX encounters (% I-PDX x PD). Since LOS tends to be longer in I-PDX, we also calculated DOT with adjustment for actual extracted IPDs. We then rank ordered study hospitals based on standard DOT / 1,000 PD, NHSN SAAR metrics, and our novel DOT / (% I-PDX x PD) and DOT / 1,000 IPD metrics.

Results

The proportion of I-PDX was highly variable among hospitals, with a system-wide median of 37.27% (range 23.48 - 43.32) (Figure 1). Using DOT / 1,000 patient days for 1 year, Hospital A was the lowest in the system and hospital H was the highest (Figure 2). However, after adjusting for the proportion of patients with I-PDX encounters and IPDs, hospital rank changed considerably, i.e. Hospital H and C respectively ranked lowest and Hospital A was highest.

Conclusion

These novel infection diagnoses PD denominators more closely associated facility level infection burden with AU, for a more refined rank order within the health system. These metrics provide an example of a parsimonious adjustment using patient level data that is already collected at any facility. Next steps might include indirect standardization using PDX categories and other patient level factors readily collected.

Disclosures

Melissa D. Johnson, PharmD, Charles River Laboratories: Grant/Research Support|Entasis: Honoraria|Merck: Grant/Research Support|Pfizer: Grant/Research Support|Scynexis: Grant/Research Support|Theratechnologies: Grant/Research Support|UpToDate: Honoraria Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties Angelina Davis, PharmD, M.S., Merck & Co.: Honoraria.

1571. Hospital COVID-19 Burden Impact on Inpatient Antibiotic Use Rates

Background

COVID-19 shifted antibiotic stewardship program resources and changed antibiotic use (AU). Shifts in patient populations with COVID surges, including pauses to surgical procedures, and dynamic practice changes makes temporal associations difficult to interpret. Our analysis aimed to address the impact of COVID on AU after adjusting for other practice shifts.

Methods

We performed a longitudinal analysis of AU data from 30 Southeast US hospitals. Three pandemic phases (1: 3/20–6/20; 2: 7/20–10/20; 3: 11/20–2/21) were compared to baseline (1/2018–1/2020). AU (days of therapy (DOT)/1000 patient days (PD)) was collected for all antimicrobial agents and specific subgroups: broad spectrum (NHSN group for hospital-onset infections), CAP (ceftriaxone, azithromycin, levofloxacin, moxifloxacin, and doxycycline), and antifungal. Monthly COVID burden was defined as all PD attributed to a COVID admission. We fit negative binomial GEE models to AU including phase and interaction terms between COVID burden and phase to test the hypothesis that AU changes during the phases were related to COVID burden. Models included adjustment for Charlson comorbidity, surgical volume, time since 12/2017 and seasonality.

Results

Observed AU rates by subgroup varied over time; peaks were observed for different subgroups during distinct pandemic phases (Figure). Compared to baseline, we observed a significant increase in overall, broad spectrum, and CAP groups during phase 1 (Table). In phase 2, overall and CAP AU was significantly higher than baseline, but in phase 3, AU was similar to baseline. These phase changes were separate from effects of COVID burden, except in phase 1 where we observed significant effects on antifungal (increased) and CAP (decreased) AU (Table).

Conclusion

Changes in hospital AU observed during early phases of the COVID pandemic appeared unrelated to COVID burden and may have been due to indirect pandemic effects (e.g., case mix, healthcare resource shifts). By pandemic phase 3, these disruptive effects were not as apparent, potentially related to shifts in non-COVID patient populations or ASP resources, availability of COVID treatments, or increased learning, diagnostic certainty, and provider comfort with avoiding antibacterials in patients with suspected COVID over time.

Disclosures

Melissa D. Johnson, PharmD, Biomeme: Licensed Transcriptional Signature for Candidemia|Charles River Laboratories: Grant/Research Support|Entasis Therapeutics: Advisor/Consultant|Merck & Co. Inc: Advisor/Consultant|Merck & Co. Inc: Grant/Research Support|Pfizer, Inc.: Advisor/Consultant|Scynexis Inc.: Grant/Research Support|Theratechnologies: Advisor/Consultant Angelina Davis, PharmD, M.S., Merck & Co.: Honoraria Sonali D. Advani, MBBS, MPH, FIDSA, Locus Biosciences: Advisor/Consultant|Locus Biosciences: Honoraria|Sysmex America: Advisor/Consultant Ibukun Kalu, MD, Pfizer, Inc.: Institutional support for clinical trial Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties.

Top Myths of Diagnosis and Management of Infectious Diseases in Hospital Medicine

Antimicrobial agents are among the most frequently prescribed medications during hospitalization. However, approximately 30% to 50% or more of inpatient antimicrobial use is unnecessary or suboptimal. Herein, we describe 10 common myths of diagnosis and management that often occur in the hospital setting. Further, we discuss supporting data to dispel each of these myths. This analysis will provide hospitalists and other clinicians with a foundation for rational decision-making about antimicrobial use and support antimicrobial stewardship efforts at both the patient and institutional levels.

106. Pandemic Pinch: The Impact of COVID Response on Antimicrobial Stewardship Program (ASP) Resource Allocation

Background

The COVID-19 pandemic placed a strain on inpatient clinical and hospital programs due to increased patient volume and rapidly evolving data on best COVID-19 management strategies. However, the impact of the pandemic on ASPs has not been well described.

Methods

We performed a cross-sectional electronic survey of stewardship pharmacy and physician leaders in 37 hospitals within the Duke Antimicrobial Stewardship Outreach Network (DASON) (community) and Duke/UNC Health systems (academic) in April-May 2021. The survey included 60 questions related to staffing changes, use of COVID-targeted therapies, related restrictions, and medication shortages.

Results

Twenty-seven facilities responded (response rate of 73%). Pharmacy personnel was reduced in 17 (63%) facilities by an average of 16%. Impacted pharmacy personnel included the stewardship lead in 15/17 (88.2%) hospitals. Converting to remote work was rare and only reported in academic institutions (n=2, 7.4%). ASP personnel were reassigned to non-stewardship duties in 12 (44%) hospitals with only half returning to routine ASP work as of May 2021. Respondents estimated that 62% of routine ASP activities were diverted during the time of the pandemic. Non-traditional, pandemic-related ASP activities included managing multiple drug shortages, of which ventilator support medications (91%) were most common affecting patient care at 52% of facilities. Steroid and hydroxychloroquine shortages were less frequent (44% and 22%, respectively). Despite staff reductions, pharmacists often served as primary contact for remdesivir approvals either using a criteria-based checklist at dispensing or as part of a dedicated phone approval team (Figure). Most (77%) hospitals used a criteria-based pharmacist review strategy after remdesivir FDA approval. Restriction processes for other COVID-19 therapies such as tocilizumab, hydroxychloroquine, and ivermectin were reported in 64% of hospitals.

Remdesivir Allocation Strategy

Proportion of facilities implementing specific remdesivir allocation strategies from the time of the first US Food and Drug Administration (FDA) Emergency Use Authorization (EUA) through FDA approval

Conclusion

Pandemic response diverted routine ASP work and has not yet returned to baseline. Despite the reduction in pharmacy personnel due to the pandemic, the ASP pharmacy lead took on a novel and critical stewardship role throughout the pandemic exemplified by their involvement in novel treatment allocation for COVID patients.

Disclosures

Melissa D. Johnson, PharmD, MHS, Astellas (Consultant, Grant/Research Support)Charles River Laboratories (Grant/Research Support)Cidara (Consultant)Merck & Co (Consultant, Research Grant or Support)Paratek (Consultant)Pfizer (Consultant)Scynexis (Scientific Research Study Investigator)Theratechnologies (Consultant)UpToDate (Other Financial or Material Support, Author Royalties) Sonali D. Advani, MBBS, MPH, Nothing to disclose Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties)

14. Effects of an Opt-Out Protocol for Antibiotic De-escalation among Selected Patients with Suspected Sepsis: The DETOURS Trial

Background

Sepsis guidelines recommend daily review to de-escalate or stop antibiotics in appropriate patients. We conducted a randomized controlled trial (NCT03517007) of an opt-out protocol to decrease unnecessary antibiotics in selected patients with suspected sepsis.

Methods

We evaluated non-ICU adults remaining on broad-spectrum antibiotics with negative blood cultures at 48-96 hours at ten U.S. hospitals during September 2018-May 2020. A 23-item safety check excluded patients with ongoing signs of infection, concerning or inadequate microbiologic data, or high-risk conditions (Figure 1). Eligible patients were randomized to the opt-out protocol vs. usual care. The primary outcome was 30-day post-enrollment antibacterial days of therapy (DOT). Clinicians caring for intervention patients were contacted by a pharmacist or physician to encourage antibiotic discontinuation or de-escalation using opt-out language, discuss rationale for continuing antibiotics, working diagnosis, and de-escalation and duration plans. Hurdle models separately compared the odds of antibiotic continuation and DOT distributions among those who continued antibiotics.

Components of the De-Escalating Empiric Therapy: Opting-OUt of Rx in Selected patients with Suspected Sepsis (DETOURS) Trial Protocol

Results

Among 9606 screened, 767 (8%) were enrolled (Figure 2). Common reasons for exclusion were antibiotics given prior to blood culture (35%), positive culture from non-blood sites (26%), and increased oxygen requirement (21%). Intervention patients had 32% lower odds of antibiotic continuation (79% vs. 84%, OR 0.68, 95% confidence interval [0.47, 0.98]). DOT distributions among those who continued antibiotics were similar (ratio of means 1.06 [0.88-1.26], Figure 3). Fewer intervention patients were exposed to extended-spectrum agents (38% vs. 44%). Common reasons for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was not safe (31%). Safety outcomes such as mortality, readmission, sepsis relapse, C. difficile, and length of stay did not differ.

DETOURS Trial Flow Diagram

Flow of participants through the DETOURS Trial.

Observed Days of Antibiotic Therapy Among Intervention and Control Subjects in the DETOURS Trial

Post-enrollment days of antibiotic therapy among 767 DETOURS Trial participants in 10 US acute care hospitals within 30 days after enrollment. Dark pink color indicates percent overlap between intervention (purple) and control (light pink) groups.

Conclusion

In this patient-level randomized trial of a stewardship intervention, the opt-out de-escalation protocol targeting selected patients with suspected sepsis resulted in more antibiotic discontinuations but did not affect safety events.

Disclosures

Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties) Michael Z. David, MD PhD, GSK (Board Member) Michael Klompas, MD, MPH, UpToDate (Other Financial or Material Support, Chapter Author)

Effects of a Collaborative, Community Hospital Network for Antimicrobial Stewardship Program Implementation

BACKGROUND

Individual hospitals may lack expertise, data resources, and educational tools to support antimicrobial stewardship programs (ASP).

METHODS

We established a collaborative, consultative network focused on hospital ASP implementation. Services included on-site expert consultation, shared database for routine feedback and benchmarking, and educational programs. We performed a retrospective, longitudinal analysis of antimicrobial use (AU) in 17 hospitals that participated for at least 36 months during 2013-2018. ASP practice was assessed using structured interviews. Segmented regression estimated change in facility-wide AU after a 1-year assessment, planning, and intervention initiation period. Year one AU trend (1 to 12 months) and AU trend following the first year (13 to 42 months) were compared using relative rates (RR). Monthly AU rates were measured in days of therapy (DOT) per 1,000 patient days for overall AU, specific agents, and agent groups.

RESULTS

Analyzed data included over 2.5 million DOT and almost 3 million patient-days. Participating hospitals increased ASP-focused activities over time. Network-wide overall AU trends were flat during the first 12 months after network entry but decreased thereafter (RR month 42 vs month 13, 0.95, 95% Confidence Interval (CI) 0.91-0.99.) Large variation was seen in hospital-specific AU. Fluoroquinolone use was stable during year one, then dropped significantly. Other agent groups demonstrated a non-significant downward trajectory after year one.

CONCLUSIONS

Network hospitals increased ASP activities and demonstrated decline in AU over a 42-month period. A collaborative, consultative network is a unique model in which hospitals can access ASP implementation expertise to support long-term program growth.

Stabilization of Liner Implosions via a Dynamic Screw Pinch

Magnetically driven implosions are susceptible to magnetohydrodynamic instabilities, including the magneto-Rayleigh-Taylor instability (MRTI). To reduce MRTI growth in solid-metal liner implosions, the use of a dynamic screw pinch (DSP) has been proposed [P. F. Schmit et al., Phys. Rev. Lett. 117, 205001 (2016)PRLTAO0031-900710.1103/PhysRevLett.117.205001]. In a DSP configuration, a helical return-current structure surrounds the liner, resulting in a helical magnetic field that drives the implosion. Here, we present the first experimental tests of a solid-metal liner implosion driven by a DSP. Using the 1-MA, 100-200-ns COBRA pulsed-power driver, we tested three DSP cases (with peak axial magnetic fields of 2 T, 14 T, and 20 T) and a standard z-pinch (SZP) case (with a straight return-current structure and thus zero axial field). The liners had an initial radius of 3.2 mm and were made from 650-nm-thick aluminum foil. Images collected during the experiments reveal that helical MRTI modes developed in the DSP cases, while nonhelical (azimuthally symmetric) MRTI modes developed in the SZP case. Additionally, the MRTI amplitudes for the 14-T and 20-T DSP cases were smaller than in the SZP case. Specifically, when the liner had imploded to half of its initial radius, the MRTI amplitudes for the SZP case and for the 14-T and 20-T DSP cases were, respectively, 1.1±0.3  mm, 0.7±0.2  mm, and 0.3±0.1  mm. Relative to the SZP, the stabilization obtained using the DSP agrees reasonably well with theoretical estimates.

2089. Effect of the Duke Antimicrobial Stewardship Outreach Network (DASON): A Multi-Center Time Series Analysis

Background

DASON is a 30-member, community hospital network in the southeastern United States that supports the development and growth of local antibiotic stewardship programs (ASPs). Collaborative activities include on-site visits from liaison clinical pharmacists, data sharing for routine feedback and benchmarking, and educational programs.

Methods

We performed a retrospective cohort analysis of antibiotic use (AU) in 17 hospitals that participated in DASON for a minimum of 42 months during 2013–2018. Segmented negative binomial regression models were used to estimate the change in facility-wide AU after an initial 1-year assessment, planning, and ASP intervention initiation period. Baseline AU trend (1 to 12 months) was compared against AU following the first year (13 to 42 months). Monthly AU rates were measured in days of therapy (DOT) per 1,000 patient-days (pd). Models assessed overall AU and specific antibiotic groups, as defined by the National Healthcare Safety Network AU option. The models controlled for hospital size, presence of a pre-existing formal ASP upon network entry, and year of network entry.

Results

Hospital data included a total of 2,988,930 pd over 5 years. Facility-wide AU was increasing during the first year of network entry and then began decreasing by 0.2% per month (P = 0.01, figure). Fluoroquinolone use was stagnant in year one and then decreased by 1.5% per month (P ≤ 0.001, figure). Antifungal agents were decreasing in year one and continued to decrease 0.7% per month thereafter (P = 0.03, figure). Agents predominantly used for resistant Gram-positive infections and broad-spectrum agents used for hospital-onset infections were increasing during year one and then attenuated afterward, though the slope change did not reach statistical significance. The presence of a pre-existing formal ASP was not a significant covariate in any model, while bed size and year of network entry significantly contributed to models of some antibiotic groups.

Conclusion

Participation in DASON was associated with a decline in total AU and fluoroquinolone use, and a trend toward attenuated use of other broad-spectrum agents in community hospitals. Collaborative network experiences can help local ASPs achieve reductions in AU.

Disclosures

All authors: No reported disclosures.

1013. Electronic Assessment of Empiric Antibiotic Prescribing Using Diagnosis Codes

Background

Antimicrobial stewardship programs (ASPs) must understand empiric choices for specific disease syndromes to assess adherence to local empiric treatment guidelines. Electronically-derived metrics to track empiric therapy choices would allow ASPs to target areas for intervention without significant data collection burden.

Methods

Admissions from 10 community hospitals between 7/2016 and December 2018 were reviewed to identify those with common infectious syndromes: pneumonia (PNA), urinary tract infection (UTI) and skin and soft-tissue infection (SSTI). Admissions with a syndrome of interest were identified using AHRQ clinical classifications software codes based on ICD-10 codes for infection at the time of discharge. Admissions were categorized as having the syndrome of interest with or without sepsis. Antibiotics received during the first 48 hours of inpatient admission were obtained from electronic medication administration records. The proportion of syndrome admissions receiving specific antibiotic agents was determined to evaluate initial treatment choices as compared with local empiric guidelines. Antibiotic categories were not mutually exclusive, admissions receiving combination therapy were included in the count for each individual agent as well as the combination group. The denominator was the count of admissions with the syndrome of interest. Distributions were tracked over time to observe the effects of ASP intervention.

Results

The analysis included 49,303 admissions. The most common diagnosis was UTI (30%) followed by PNA (23%). Empiric antibiotic use varied by syndrome (Figure 1). In general, patients with a targeted infectious diagnosis and sepsis received more broad-spectrum agents than those without sepsis. SSTI was an exception, but few patients admitted with SSTI did not also have presumed sepsis. Longitudinal analysis demonstrated shifts from less preferred agents to guideline-concordant choices. For example, for admissions with a diagnosis of PNA, we observed a steady year on year increase in ceftriaxone (preferred) while levofloxacin (avoided in local guidelines) declined. (Figure 2)

Conclusion

Syndrome-specific diagnosis codes were helpful in assessing empiric antibiotic selection and may assist ASPs in improving empiric guideline adherence.

Disclosures

All authors: No reported disclosures.

996. Impact of Penicillin Allergy Labels on Carbapenem Use in a Multi-Center Study

Background

Antibiotic allergy labels lead to excess exposure to broad-spectrum antibiotics and can result in patient harm. We aimed to describe the prevalence of penicillin allergy labels (PAL) across a variety of hospital settings and its association with carbapenem exposure.

Methods

We performed a retrospective cohort analysis of inpatient admissions from 14 hospitals in the Duke Antimicrobial Stewardship Outreach Network (DASON) and Duke Health System from 2016 to 2018. Data were collected from the DASON central database which is derived from electronic health record extracts. PAL was defined from drug allergy documentation indicating any reaction to penicillin or its related agents, but did not include labels for other β-lactam agents (e.g., cephalosporin). Carbapenem exposure was defined as a binary variable indicating receipt of at least one dose of meropenem, ertapenem, doripenem or imipenem on an inpatient unit. The association between PAL and carbapenem exposure was assessed using multivariable logistical regression with candidate covariates including age, gender, comorbidity score, and exposure to intensive care or hematology/oncology unit. Hospital-level PAL prevalence was defined as the percentage of inpatient admissions. Hospital-level carbapenem use rates were assessed as days of therapy (DOT) per 1000 patient-days and stratified by PAL to understand the portion of use associated with PAL.

Results

Of the 727,168 admissions included in this study, 84,033 (11.6%) patients had a PAL. The majority of admissions with documented PAL were in patients >65 years old (47.9%, n = 40,240) and female (57.8%, n = 418,472). PAL was associated with a 2-fold higher risk of receipt of carbapenem (adjusted odds ratio 2.13, 95% CI 0.89–2.40, P < 0.0001). PAL prevalence varied among hospitals (median 14%, range 5–20%). Hospitals with antibiotic allergy-focused stewardship programs (ASP) had a similar PAL prevalence (median 13.8 vs. 15.9%, P = 0.08), but the percent of carbapenem DOT used in patients with PAL was similar (median 23% vs. 24%, P = 0.6).

Conclusion

PAL was associated with increased carbapenem exposure on the patient level. Allergy-focused ASP activities may affect PAL but it is unclear whether it reduces carbapenem use based on these observational data.

Disclosures

All authors: No reported disclosures.

2087. Electronic Capture and Feedback of Standardized Antibiotic Clinical Indications Data Among Community Hospitals

Background

Antibiotic clinical indications allow stewardship programs to assess therapy appropriateness; however, many hospitals that require antibiotic indications upon order entry lack standardized mapping of indications leading to variability in entered values. Electronic capture and feedback of standardized antibiotic clinical indications data may allow hospitals to more effectively compare indication-specific prescribing trends among facilities.

Methods

We collected antibiotic indications from electronic medication orders for 6 DASON hospitals. These indications were mapped to a list of 15 standardized indication categories created by consensus of the DASON stewardship team. To demonstrate the feasibility and utility of standardized clinical indications mapping, we evaluated agents given for the indication C. difficile infection (CDI) in 2018. Differences between the hospitals were compared with highlight the added benefit of standardized indication data in evaluating antibiotic use and adoption of local guidelines.

Results

For 249,916 antibiotic days of therapy (DOT) with an indication available, a total of 125 unique indications were reported. Of note, 3 facilities allowed more than one indication to be entered at prescriber discretion. The distribution of antibiotic DOT mapped to the standardized indication list can be seen in Figure 1. The most common indication was the other category (19.5%). These were primarily other, no additional information (47%) or empiric therapy for an unknown source of infection (17%). Additional indications in the other category included chronic obstructive pulmonary disease exacerbations and sexually transmitted infections (< 5% each). Figure 2 depicts the agents used for CDI indication between facilities. Despite universal adoption of local guidelines where oral vancomycin is the drug of choice for treating CDI, there was variability seen in vancomycin CDI DOT (range: 60 – 80% of CDI DOT).

Conclusion

Stewardship programs can implement standardized antimicrobial indications to facilitate electronic capture, feedback, and comparison and efficiently identify stewardship targets. Additionally, hospitals may use these data to explore the appropriateness of antibiotic use.

Disclosures

All authors: No reported disclosures.

Impact of automatic infectious diseases consultation on the management of fungemia at a large academic medical center

PURPOSE

The impact of automatic infectious diseases (ID) consultation for inpatients with fungemia at a large academic medical center was studied.

METHODS

In this single-center, retrospective study, the time to appropriate antifungal therapy before and after implementing a policy requiring automatic ID consultation for the management of fungemia for all patients with an inpatient positive blood culture for fungus was examined. The rates of ID consultation; the likelihood of receiving appropriate antifungal therapy; central venous catheter (CVC) removal rates; performance of ophthalmologic examinations; infection-related length of stay (LOS); rates of all-cause inhospital mortality, death, or transfer to an intensive care unit within 7 days of first culture; and inpatient cost of antifungals were also evaluated.

RESULTS

A total of 173 unique episodes (94 and 79 in the control and intervention groups, respectively) were included. Candida species were the most frequently cultured organisms, isolated from over 90% of patients in both groups. No differences were observed between the control and intervention groups in time to appropriate therapy, infection-related LOS, or time to CVC removal. However, patients in the intervention group were more likely than those in the control group to receive appropriate antifungal therapy (p = 0.0392), undergo ophthalmologic examination (p = 0.003), have their CVC removed (p = 0.0038), and receive ID consultation (p = 0.0123). Inpatient antifungal costs were significantly higher in the intervention group (p = 0.0177).

CONCLUSION

While automatic ID consultation for inpatients with fungemia did not affect the time to administration of appropriate therapy, improvement was observed for several process indicators, including rates of appropriate antifungal therapy selection, time to removal of CVCs, and performance of ophthalmologic examinations.

The α2,3-selective potentiator of GABAA receptors, KRM-II-81, reduces nociceptive-associated behaviors induced by formalin and spinal nerve ligation in rats

Clinical evidence indicates that positive allosteric modulators (PAMs) of GABAA receptors have analgesic benefit in addition to efficacy in anxiety disorders. However, the utility of GABAA receptor PAMs as analgesics is compromised by the central nervous system side effects of non-selective potentiators. A selective potentiator of GABAA receptors associated with α2/3 subunits, KRM-II-81(5-(8-ethynyl-6-(pyridin-2-yl)-4H-benzo[f]imidazo[1,5-a][1,4]diazepin-3-yl)oxazole), has demonstrated anxiolytic, anticonvulsant, and antinociceptive effects in rodents with reduced motoric side effects. The present study evaluated the potential of KRM-II-81 as a novel analgesic. Oral administration of KRM-II-81 attenuated formalin-induced flinching; in contrast, diazepam was not active. KRM-II-81 attenuated nociceptive-associated behaviors engendered by chronic spinal nerve ligation (L5/L6). Diazepam decreased locomotion of rats at the dose tested in the formalin assay (10 mg/kg) whereas KRM-II-81 produced small decreases that were not dose-dependent (10-100 mg/kg). Plasma and brain levels of KRM-II-81 were used to demonstrate selectivity for α2/3- over α1-associated GABAA receptors and to define the degree of engagement of these receptors. Plasma and brain concentrations of KRM-II-81 were positively-associated with analgesic efficacy. GABA currents from isolated rat dorsal-root ganglion cultures were potentiated by KRM-II-81 with an ED50 of 32 nM. Measures of respiratory depression were reduced by alprazolam whereas KRM-II-81 was either inactive or produced effects with lower potency and efficacy. These findings add to the growing body of data supporting the idea that α2/3-selective GABAA receptor PAMs will have efficacy and tolerability as pain medications including those for neuropathic pain. Given their predicted anxiolytic effects, α2/3-selective GABAA receptor PAMs offer an additional inroad into the management of pain.

Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals

IMPORTANCE

Sepsis is present in many hospitalizations that culminate in death. The contribution of sepsis to these deaths, and the extent to which they are preventable, is unknown.

OBJECTIVE

To estimate the prevalence, underlying causes, and preventability of sepsis-associated mortality in acute care hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Cohort study in which a retrospective medical record review was conducted of 568 randomly selected adults admitted to 6 US academic and community hospitals from January 1, 2014, to December 31, 2015, who died in the hospital or were discharged to hospice and not readmitted. Medical records were reviewed from January 1, 2017, to March 31, 2018.

MAIN OUTCOMES AND MEASURES

Clinicians reviewed cases for sepsis during hospitalization using Sepsis-3 criteria, hospice-qualifying criteria on admission, immediate and underlying causes of death, and suboptimal sepsis-related care such as inappropriate or delayed antibiotics, inadequate source control, or other medical errors. The preventability of each sepsis-associated death was rated on a 6-point Likert scale.

RESULTS

The study cohort included 568 patients (289 [50.9%] men; mean [SD] age, 70.5 [16.1] years) who died in the hospital or were discharged to hospice. Sepsis was present in 300 hospitalizations (52.8%; 95% CI, 48.6%-57.0%) and was the immediate cause of death in 198 cases (34.9%; 95% CI, 30.9%-38.9%). The next most common immediate causes of death were progressive cancer (92 [16.2%]) and heart failure (39 [6.9%]). The most common underlying causes of death in patients with sepsis were solid cancer (63 of 300 [21.0%]), chronic heart disease (46 of 300 [15.3%]), hematologic cancer (31 of 300 [10.3%]), dementia (29 of 300 [9.7%]), and chronic lung disease (27 of 300 [9.0%]). Hospice-qualifying conditions were present on admission in 121 of 300 sepsis-associated deaths (40.3%; 95% CI 34.7%-46.1%), most commonly end-stage cancer. Suboptimal care, most commonly delays in antibiotics, was identified in 68 of 300 sepsis-associated deaths (22.7%). However, only 11 sepsis-associated deaths (3.7%) were judged definitely or moderately likely preventable; another 25 sepsis-associated deaths (8.3%) were considered possibly preventable.

CONCLUSIONS AND RELEVANCE

In this cohort from 6 US hospitals, sepsis was the most common immediate cause of death. However, most underlying causes of death were related to severe chronic comorbidities and most sepsis-associated deaths were unlikely to be preventable through better hospital-based care. Further innovations in the prevention and care of underlying conditions may be necessary before a major reduction in sepsis-associated deaths can be achieved.

Childhood neighborhood context and adult substance use problems: the role of socio-economic status at the age of 30 years

OBJECTIVES

To examine whether the (a) childhood neighborhood context predicts alcohol use disorder, nicotine dependence, and cannabis use disorder symptoms at the age of 39 years; and (b) socio-economic status during young adulthood mediates these relationships. Gender differences were also examined.

STUDY DESIGN

The Seattle Social Development Project is a prospective longitudinal study of 808 individuals followed up from ages 10 to 39 years in Seattle, Washington, United States. The sample was gender balanced (51% were men).

METHODS

Alcohol, nicotine, and cannabis use disorder symptoms were assessed using the Diagnostic and Statistical Manual of Mental Disorders IV-based Diagnostic Interview Schedule. Childhood neighborhood data consisted of 10 neighborhood-level variables from the 1990 national census, which were consolidated using principal component analyses. Two components with eigenvalues greater than 1 were extracted-neighborhood disadvantage and neighborhood stability. Educational attainment and employment status represented socio-economic status during young adulthood. Covariates included baseline symptoms of psychopathology, baseline substance use, gender, ethnicity, and childhood socio-economic status at the family level. Negative binomial regression was used as the primary modeling strategy. Six models for each outcome measure were estimated. The first three models examined associations between two neighborhood components and each substance use outcome measure. Next, we tested the second research question by adding unemployment and college graduate indicators at the age of 30 years as potential mediators underlying the link between the childhood neighborhood context and three substance use measures.

RESULTS

Study findings revealed that childhood neighborhood stability significantly reduced alcohol and cannabis use disorder symptoms nearly 3 decades later. Path analyses suggested that socio-economic status during the transition to adulthood did not influence these relationships but rather had independent effects on problematic nicotine and cannabis use. Furthermore, the effects of childhood neighborhood factors on problematic nicotine use were stronger for men.

CONCLUSIONS

Neighborhood characteristics during childhood may be important factors for alcohol and cannabis use disorder symptoms among adults and nicotine dependence disorder symptoms among men. Prevention efforts that address community stability and disadvantage can and should start in childhood, with a focus on intervention targets that might gain salience later in life to discourage the development and persistence of problematic substance use in adulthood.

The cost of oropharyngeal cancer in England: A retrospective hospital data analysis

OBJECTIVES

To estimate the total costs of treating head and neck cancers, specifically oropharyngeal, laryngeal and oral cavity cancer, in secondary care facilities in England during the period 2006/2007 to 2010/2011.

DESIGN

Patient records were extracted from an English hospital database to estimate the number of patients treated for oropharyngeal, laryngeal and oral cavity cancer in England. Identified resource use was linked to published United Kingdom cost estimates to quantify the reimbursement of treatment through the Payment by Results system.

SETTING

Retrospective hospital data analysis.

PARTICIPANTS

From the hospital data, patient records of patients treated for oropharyngeal, laryngeal and oral cavity cancer were selected.

MAIN OUTCOME MEASURES

Annual total costs of treatment, stratified by inpatient and outpatient setting and by male and female patients.

RESULTS

From 2006/2007 to 2010/2011, total costs of treatment across the three head and neck cancer sites were estimated to be approximately £309 million, with 90% attributable to inpatient care (bundled costs). Oropharyngeal cancer accounted for 37% of total costs. Costs and patient numbers increased over time, largely due to a rise in oropharyngeal cancer, where total costs increased from £17.21 million to £30.32 million, with over 1400 (52%) more inpatients treated in 2010/11 compared to 2006/07.

CONCLUSIONS

In 4 years, the number of patients with oropharyngeal cancer receiving some form of inpatient care increased by more than half, and associated costs increased by three quarters. This reinforces the case for prevention and early detection strategies to help contain this epidemiological and economic burden.

Chronic exposure to dim artificial light at night decreases fecundity and adult survival in Drosophila melanogaster

The presence of artificial light at night is expanding in geographical range and increasing in intensity to such an extent that species living in urban environments may never experience natural darkness. The negative ecological consequences of artificial night lighting have been identified in several key life history traits across multiple taxa (albeit with a strong vertebrate focus); comparable data for invertebrates is lacking. In this study, we explored the effect of chronic exposure to different night-time lighting intensities on growth, reproduction and survival in Drosophila melanogaster. We reared three generations of flies under identical daytime light conditions (2600lx) and one of four ecologically relevant ALAN treatments (0, 1, 10 or 100lx), then explored variation in oviposition, number of eggs produced, juvenile growth and survival and adult survival. We found that, in the presence of light at night (1, 10 and 100lx treatments), the probability of a female commencing oviposition and the number of eggs laid was significantly reduced. This did not translate into differences at the juvenile phase: juvenile development times and the probability of eclosing as an adult were comparable across all treatments. However, we demonstrate for the first time a direct link between chronic exposure to light at night (greater than 1lx) and adult survival. Our data highlight that ALAN has the capacity to cause dramatic shifts in multiple life history traits at both the individual and population level. Such shifts are likely to be species-specific, however a more in depth understanding of the broad-scale impact of ALAN and the relevant mechanisms driving biological change is urgently required as we move into an increasing brightly lit future.

Further evaluation of the potential anxiolytic activity of imidazo[1,5-a][1,4]diazepin agents selective for α2/3-containing GABAA receptors

Positive allosteric modulators of GABAA receptors transduce a host of beneficial effects including anxiolytic actions. We have recently shown that bioavailability and anxiolytic-like activity can be improved by eliminating the ester functionality in imidazo[1,5-a][1,4]diazepines. In the present series of experiments, we further substantiate the value of heterocyle replacement of the ester for potential treatment of anxiety. None of three esters was active in a Vogel conflict test in rats that detects anxiolytic drugs like diazepam. Compounds 7 and 8, ester bioisosters, were selective for alpha 2 and 3 over alpha 1-containing GABAA receptors but also had modest efficacy at GABAA alpha 5-containing receptors. Compound 7 was efficacious and potent in this anxiolytic-detecting assay without affecting non-punished responding. The efficacies of the esters and of compound 7 were predicted from their efficacies as anticonvulsants against the GABAA antagonist pentylenetetrazole (PTZ). In contrast, the related structural analog, compound 8, did not produce anxiolytic-like effects in rats despite anticonvulsant efficacy. These data thus support the following conclusions: 1) ancillary pharmacological actions of compound 8 might be responsible for its lack of anxiolytic-like efficacy despite its efficacy as an anticonvulsant 2) esters of imidazo[1,5-a][1,4]diazepines do not demonstrate anxiolytic-like effects in rats due to their low bioavailability and 3) replacement of the ester function with suitable heterocycles markedly improves bioavailability and engenders molecules with the opportunity to have potent and efficacious effects in vivo that correspond to human anxiolytic actions.

Pathology-based staging for HPV-positive squamous carcinoma of the oropharynx

OBJECTIVE

The rapid worldwide rise in incidence of human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) has generated studies confirming this disease as an entity distinct from traditional OPSCC. Based on pathology, surgical studies have revealed prognosticators specific to HPV-positive OPSCC. The current AJCC/UICC staging and pathologic nodal (pN)-classification do not differentiate for survival, demonstrating the need for new, HPV-specific OPSCC staging. The objective of this study was to define a pathologic staging system specific to HPV-positive OPSCC.

METHODS

Data were assembled from a surgically-managed, p16-positive OPSCC cohort (any T, any N, M0) of 704 patients from five cancer centers. Analysis was performed for (a) the AJCC/UICC pathologic staging, (b) newly published clinical staging for non-surgically managed HPV-positive OPSCC, and (c) a novel, pathology-based, "HPVpath" staging system that combines features of the primary tumor and nodal metastases.

RESULTS

A combination of AJCC/UICC pT-classification and pathology-confirmed metastatic node count (⩽4 versus ⩾5) yielded three groups: stages I (pT1-T2, ⩽4 nodes), II (pT1-T2, ⩾5 nodes; pT3-T4, ⩽4 nodes), and III (pT3-T4, ⩾5 nodes), with incrementally worse prognosis (Kaplan-Meier overall survival of 90%, 84% and 48% respectively). Existing AJCC/UICC pathologic staging lacked prognostic definition. Newly published HPV-specific clinical stagings from non-surgically managed patients, although prognostic, showed lower precision for this surgically managed cohort.

CONCLUSIONS

Three loco-regional "HPVpath" stages are identifiable for HPV-positive OPSCC, based on a combination of AJCC/UICC primary tumor pT-classification and metastatic node count. A workable, pathologic staging system is feasible to establish prognosis and guide adjuvant therapy decisions in surgically-managed HPV-positive OPSCC.

Mechanisms linking high school graduation to health disparities in young adulthood: a longitudinal analysis of the role of health behaviours, psychosocial stressors, and health insurance

OBJECTIVES

This study examined three competing mechanisms in the link between educational attainment and health among young adults: (a) a health behaviour mechanism; (b) a psychosocial stressor mechanism; and (c) a health insurance mechanism. The central research question was the pervasiveness and specificity of these mechanisms in the link between low educational attainment and health outcomes during young adulthood.

STUDY DESIGN

A prospective longitudinal study was conducted with 808 men and women followed to age 33 years in the USA.

METHODS

Health outcomes included major depressive disorder, obesity, chronic health conditions, and self-rated health. The focal predictor was educational attainment at age 21. The roles of the health behaviour mechanism (heavy episodic drinking, cigarette smoking, and meeting physical activity guidelines), the psychosocial stressor mechanism (stressful life events, perceived financial stress, and lack of control at work), and having health insurance (either through their employer or union or via family members) in the link between education and varying health outcomes were assessed using path analyses.

RESULTS

Lack of health insurance emerged as a statistically significant explanatory factor underlying the association of education with depression and self-rated health. Health behaviours, specifically smoking and physical activity, were statistically significant intervening factors for obesity and self-rated health.

CONCLUSIONS

The processes linking educational attainment to health inequalities begin unfolding during young adulthood. The salience of different mechanisms is specific to a health outcome rather than pervasive across multiple health outcomes. Public health policies with a broad spectrum of components, particularly focussing on smoking, physical activity, and lack of health insurance, are recommended to promote educational equalities in multiple health outcomes among young adults.

Saturation Binding of Nicotine to Synthetic Neuromelanin Demonstrated by Fluorescence Spectroscopy

Neuromelanin (NM) has long been considered as an aging pigment, perhaps an unavoidable and undesirable byproduct of dopaminergic neural transmission. However, NM is carefully packaged into double membrane-bound structures within cells of the substantia nigra and other neural tissues, suggesting a beneficial function to maintaining these stores. It is well established that NM is able to concentrate toxic xenobiotics within pigmented cells due to its unique chemical environment. In doing so, such agents may confer susceptibility to Parkinson's disease (PD) as illustrated by model PD-inducing neurotoxins such as methyl-phenyl-pyridinium ion. It is possible that high-affinity binding interactions toward NM may contribute to the adverse effects of PD-inducing toxins, as well as neuroprotective agents. Here we aim to develop a generalized assay capable of elucidating the binding constants of chemical agents to synthetic and natural neuromelanins. Toward this end, a model neuromelanin synthesized from dopamine and cysteine was prepared according to published procedure. Using a UV/Visible spectroscopic assay, we show that dopamine, 6-hydroxy dopamine, and nicotine bind to the synthetic neuromelanin, while caffeine did not. More importantly, nicotine was further found to induce a fluorescence signal in the presence of NM which was used to establish a binding constant estimated at 0.65 mM. Dopamine appears to enhance this signal, also in a saturable manner, with an estimated Kd of 0.05 mM in our isolated chemical system. In summary, the micro-scale fluorescence assay described herein will allow us to overcome many of the problems inherent in the study of chemical interaction with NM through traditional spectroscopic means. Using a single standardized signal, it should now be possible to rank a number of PD-related toxins based on NM-binding affinity and shed further light on this important problem.

Role of isavuconazole in the treatment of invasive fungal infections

Despite recent advances in both diagnosis and prevention, the incidence of invasive fungal infections continues to rise. Available antifungal agents to treat invasive fungal infections include polyenes, triazoles, and echinocandins. Unfortunately, individual agents within each class may be limited by spectrum of activity, resistance, lack of oral formulations, significant adverse event profiles, substantial drug–drug interactions, and/or variable pharmacokinetic profiles. Isavuconazole, a second-generation triazole, was approved by the US Food and Drug Administration in March 2015 and the European Medicines Agency in July 2015 for the treatment of adults with invasive aspergillosis (IA) or mucormycosis. Similar to amphotericin B and posaconazole, isavuconazole exhibits a broad spectrum of in vitro activity against yeasts, dimorphic fungi, and molds. Isavuconazole is available in both oral and intravenous formulations, exhibits a favorable safety profile (notably the absence of QTc prolongation), and reduced drug–drug interactions (relative to voriconazole). Phase 3 studies have evaluated the efficacy of isavuconazole in the management of IA, mucormycosis, and invasive candidiasis. Based on the results of these studies, isavuconazole appears to be a viable treatment option for patients with IA as well as those patients with mucormycosis who are not able to tolerate or fail amphotericin B or posaconazole therapy. In contrast, evidence of isavuconazole for invasive candidiasis (relative to comparator agents such as echinocandins) is not as robust. Therefore, isavuconazole use for invasive candidiasis may initially be reserved as a step-down oral option in those patients who cannot receive other azoles due to tolerability or spectrum of activity limitations. Post-marketing surveillance of isavuconazole will be important to better understand the safety and efficacy of this agent, as well as to better define the need for isavuconazole serum concentration monitoring.

Transoral Surgery or Radiotherapy for Oropharyngeal Carcinoma - Is It Either Or…?

The management of oropharyngeal carcinoma represents an increasing clinical challenge, because of its rising incidence, particularly in younger patients as a result of human papillomavirus (HPV) infection, and because significant technological advances have occurred in radiotherapy and surgery over the last 10 years that have increased treatment options for patients, with little robust evidence yet of their relative merits. As a result, there is a lack of clinical consensus on the optimum treatment modality, reflected in wide variation in practice between different cancer networks across the UK. Here, we consider the evidence base for minimally invasive transoral surgery and for intensity-modulated radiotherapy-based primary treatment for oropharyngeal cancer, in terms of both oncological and functional outcomes. Management strategies for HPV-positive and HPV-negative disease, and for different stages of the disease, are considered. There is currently an unparalleled opportunity to shape the future management of oropharyngeal cancer, which is dependent on recruiting patients to ongoing clinical trials, in order to build an evidence base to support a clinical consensus on the optimal treatment strategies. It appears likely that future evidence-based decision-making will use both primary radiotherapy and primary surgical treatment modalities to maximise patient benefit.

Focus on JNJ-Q2, a novel fluoroquinolone, for the management of community-acquired bacterial pneumonia and acute bacterial skin and skin structure infections

JNJ-Q2 is a novel, fifth-generation fluoroquinolone that has excellent in vitro and in vivo activity against a variety of Gram-positive and Gram-negative organisms. In vitro studies indicate that JNJ-Q2 has potent activity against pathogens responsible for acute bacterial skin and skin structure infections (ABSSSI) and community-acquired bacterial pneumonia (CABP), such as Staphylococcus aureus and Streptococcus pneumoniae. JNJ-Q2 also has been shown to have a higher barrier to resistance compared to other agents in the class and it remains highly active against drug-resistant organisms, including methicillin-resistant S. aureus, ciprofloxacin-resistant methicillin-resistant S. aureus, and drug-resistant S. pneumoniae. In two Phase II studies, the efficacy of JNJ-Q2 was comparable to linezolid for ABSSSI and moxifloxacin for CABP. Furthermore, JNJ-Q2 was well tolerated, with adverse event rates similar to or less than other fluoroquinolones. With an expanded spectrum of activity and low potential for resistance, JNJ-Q2 shows promise as an effective treatment option for ABSSSI and CABP. Considering its early stage of development, the definitive role of JNJ-Q2 against these infections and its safety profile will be determined in future Phase III studies.

Injection of botulinum toxin for the treatment of post-laryngectomy pharyngoesophageal spasm-related disorders

Introduction Pharyngoesophageal spasm (PES) can cause dysphagia, central valve leak (CVL), and dypshonia in post-laryngectomy patients. Botulinum toxin has been used effectively for the treatment of PES, but data regarding patient-reported outcomes and efficacy for CVL are limited. We evaluated the results of botox injection for PES spasm using subjective and objective measures. Methods Data were collected prospectively (February 2010 to August 2013) on 13 patients undergoing botox injection for PES as identified by video fluoroscopy. We collected digital voice recordings, air-pressure measurements (APMs) for speech, and quality of life (QoL) data before and after the procedure: University of Washington QoL questionnaire (UW-QoL), MD Anderson Swallowing Inventory (MDADI) and the Voice Handicap Index (VHI-30). Results APMs for a sustained vowel decreased by 18% after botox injection, whereas maximum phonatory times increased by 63% (mean increase, 8 to 13 seconds). Sustained vowel amplitude decreased (mean, 87db to 83db) with an associated reduction in sustained vowel frequency (117Hz to 77Hz). MDADI scores improved by 10.2% overall, and UW-QoL scores showed an improvement in score of 7.6%. Mean scores for VHI-30 deteriorated by 2% overall but, when considering only those patients experiencing dysphonia, an improvement of 9.4% was seen. There was an overall net reduction for the CVL cohort of 12 speech valves in the year after injection. Conclusions Our series confirm the safety and objective efficacy of botox injection for PES. QoL measurements were less convincing, and this disparity between subjective and objective measurements must be considered when treating such patients.

Upper airway obstruction in a patient with Ehlers-Danlos syndrome

We report a case of recurrent airway obstruction episodes resulting from laryngeal hypermobility in a patient with Ehlers-Danlos syndrome. A 44-year-old woman, with known Ehlers-Danlos syndrome, presented with recent onset of episodes of upper airway obstruction due to hypermobility of her larynx. A suitable conservative management strategy proved elusive and the patient finally underwent a thyrohyoidopexy. The patient remains symptom free nine months after the procedure. This is the first report of spontaneous life threatening upper airway obstruction due to hypermobility of the suprahyoid suspensory soft tissues in Ehlers-Danlos syndrome.

Tracheal stenosis following percutaneous dilatational tracheostomy using the single tapered dilator: an MRI study

Despite widespread adoption of percutaneous dilatational tracheostomy within the critical care setting, there is still uncertainty regarding long-term complications, particularly in relation to missed or subclinical tracheal stenosis. In this study, all patients underwent tracheostomy using a single tapered dilator ≥ three months prior to enrollment and were evaluated using magnetic resonance imaging, spirometry and questionnaire. Tracheal area was recorded and deemed to be stenotic if a reduction of ≥10% was found. Fifty patients underwent magnetic resonance imaging and 49 attended for interview. Five patients were diagnosed with tracheal stenosis-none were symptomatic. Six of the 50 tracheostomies were technically difficult. Spirometry was not predictive of stenosis. A post critical care exercise tolerance of less than 100 metres was found in four tracheal stenosis patients. The prevalence of subclinical tracheal stenosis following percutaneous tracheostomy is low, with limited clinical significance. No patients required corrective surgery for tracheal stenosis. Routine airway follow-up in asymptomatic patients appears to be unwarranted.

Anaesthesia for massive retrosternal thyroidectomy in a tertiary referral centre

BACKGROUND

Retrosternal goitre (RSG) is an uncommon problem encountered rarely by anaesthetists working outside specialized head and neck (H&N) surgical units. Traditional anaesthetic teaching warns of difficult airway management in these patients. The incidence and extent of these problems is unclear.

METHODS

We have performed a retrospective review of the anaesthetic management all patients with massive RSG (extending to the aortic arch or beyond) presenting for thyroidectomy at University Hospital Aintree from January 2007 to May 2012.

RESULTS

Five hundred and seventy-three patients underwent a thyroidectomy procedure at Aintree University Hospitals NHS Foundation Trust (AUH) between January 2007 and May 2012. Of these, 34 cases were documented as having a RSG. Review of each patient's preoperative computerized tomography imaging identified 19 patients with massive RSG. There was one case of failed intubation. All other patients underwent uneventful tracheal intubation via direct laryngoscopy. All glands were removed through the neck with no requirement to proceed to sternotomy. There were no instances of postoperative respiratory problems or tracheomalacia. Three patients suffered recurrent laryngeal nerve (RLN) injuries.

CONCLUSION

When managed within a dedicated H&N operating theatre we have found a low incidence of difficult tracheal intubation, difficult mechanical ventilation nor postoperative respiratory difficulties in patients with massive RSG and mid-tracheal compression because of benign multi-nodular goitre. Surgical complications, however, are more frequent than those associated with cervical thyroidectomy with RLN injury and postoperative bleeding more likely.

Validation of a novel diagnostic standard in HPV-positive oropharyngeal squamous cell carcinoma

Background:

Human papillomavirus (HPV) testing in oropharyngeal squamous cell carcinoma (OPSCC) is now advocated. Demonstration of transcriptionally active high-risk HPV (HR-HPV) in fresh tumour tissue is considered to be the analytical ‘gold standard'. Clinical testing has focused on formalin-fixed paraffin-embedded (FFPE) tissue at the expense of sensitivity and specificity. Recently, a novel RNA in situ hybridisation test (RNAscope) has been developed for the detection of HR-HPV in FFPE tissue; however, validation against the ‘gold standard' has not been reported.

Methods:

A tissue microarray comprising FFPE cores from 79 OPSCC was tested using HR-HPV RNAscope. Analytical accuracy and prognostic capacity were established by comparison with the reference test; qRT–PCR for HR-HPV on matched fresh-frozen samples.

Results:

High-risk HPV RNAscope had a sensitivity and specificity of 97 and 93%, respectively, against the reference test. Kaplan–Meier estimates of disease-specific survival (DSS, P=0.001) and overall survival (OS, P<0.001) by RNAscope were similar to the reference test (DSS, P=0.003, OS, P<0.001) and at least, not inferior to p16 immunohistochemistry +/− HR-HPV DNA-based tests.

Conclusion:

HR-HPV RNAscope demonstrates excellent analytical and prognostic performance against the ‘gold standard'. These data suggest that the test could be developed to provide the ‘clinical standard' for assigning a diagnosis of HPV-related OPSCC.

Percutaneous tracheostomy: a 6 yr prospective evaluation of the single tapered dilator technique

BACKGROUND

The single tapered dilator (STD) percutaneous dilatational tracheostomy (PDT) technique now appears to be the single most common method of performing a tracheostomy in the critical care unit (CCU).

METHODS

A single-centre, prospective evaluation of all PDTs performed in an adult mixed surgical and medical CCU between November 2003 and October 2009 was done. All procedures were undertaken by critical care physicians. A proforma recorded intraoperative complications and technical difficulties encountered during the procedure; all patients were followed up for a minimum of 3 months for delayed complications.

RESULTS

A tracheostomy was performed on 589 patients during the study period. PDT was attempted in 576 patients and successfully completed in 572. PDT was abandoned in four patients due to bleeding, with three of these subsequently undergoing surgical tracheostomy (ST). ST was performed in 17 patients. Intraoperative technical difficulties were encountered in 149 (26%) cases. Sixteen (3%) procedures were deemed as having early complications. A further four (0.7%) cases had significant late complications including two tracheo-innominate fistulae (TIF). Both TIF patients died as a result of their complications giving a mortality directly attributable to PDT of 0.35%. There were no differences with respect to the occurrence of complications according to grade of operator.

CONCLUSIONS

PDT performed by the STD technique is a relatively safe procedure with more than 96% of procedures performed without any early or late complications. Using this technique, more than 97% of tracheostomies undertaken during the study period were performed percutaneously. Further audit at a national level is warranted to fully evaluate long-term complications after PDT.

Nutlin-3, the small-molecule inhibitor of MDM2, promotes senescence and radiosensitises laryngeal carcinoma cells harbouring wild-type p53

BACKGROUND

Primary radiotherapy (RT) is a mainstay of treatment for laryngeal squamous cell carcinoma (LSCC). Although the cure rates for early (T1) vocal cord tumours are high, RT proves ineffective in up to a third of T3 carcinomas. Moreover, RT is associated with debilitating early- and late-treatment-related toxicity, thus finding means to de-escalate therapy, while retaining/augmenting therapeutic effectiveness, is highly desirable. p53 is a key mediator of radiation responses; we therefore investigated whether Nutlin-3, a small-molecule inhibitor of MDM2 (mouse double minute 2; an essential negative regulator of p53), might radiosensitise LSCC cells.

METHODS

We performed clonogenic assays to measure radiosensitivity in a panel of LSCC cell lines (for which we determined p53 mutational status) in the presence and absence of Nutlin-3.

RESULTS

LSCC cells harbouring wild-type p53 were significantly radiosensitised by Nutlin-3 (P<0.0001; log-rank scale), and displayed increased cell cycle arrest and significantly increased senescence (P<0.001) in the absence of increased apoptosis; thus, our data suggest that senescence may mediate this increased radiosensitivity.

CONCLUSION

This is the first study showing Nutlin-3 as an effective radiosensitiser in LSCC cells that retain wild-type p53. The clinical application of Nutlin-3 might improve local recurrence rates or allow treatment de-escalation in these patients.

Outcome of late-onset hospital-acquired pneumonia related to causative organism

Pneumonia caused by Pseudomonas spp. has been associated with an increase in mortality in critical care patients. Previous assessments, however, have failed to compare outcome solely with other pathogens associated with hospital-acquired pneumonia (HAP). We have performed a retrospective review of all critical care patients with late-onset HAP (hospital inpatient stay >72 h at time of diagnosis) due to pure respiratory cultures of Pseudomonas spp., meticillin-resistant Staphylococcus aureus (MRSA) or non-pseudomonal Gram-negative (NPGN) organisms from 1998 to 2007. Casenote review involved assessments of illness severity, clinical pulmonary infection scoring (CPIS), critical care and hospital survival, and critical care length of stay. Out of 252 casenotes, 204 were reviewed. There were 186 treated cases of pneumonia. Ten patients had both pseudomonal and NPGN pneumonias during the same admission and two patients presented with community-acquired infections due to these organisms. These 12 patients were excluded from further analysis. Of the remaining 174 patients, 80 were infected with pseudomonas, 40 with MRSA and 54 had NPGN organisms. The three groups of patients were well-matched, with similar age, sex, CPIS scores, incidence of bacteraemia and Acute Physiology and Chronic Health Evaluation II scores at diagnosis. There were no outcome differences between the groups with respect to hospital and critical care survival and critical care length of stay. In this series, there appears to be no survival disadvantage associated with pseudomonal pneumonia when compared with other hospital-acquired organisms associated with HAP, where disease severity between the groups is similar.

Role of routine chest radiography after percutaneous dilatational tracheostomy

BACKGROUND

The role of routine chest radiography (CXR) after percutaneous dilatational tracheostomy (PDT) has been questioned.

METHODS

We performed a prospective observational study, on a mixed medical/surgical critical care unit in a university teaching hospital. We studied all patients undergoing PDT as part of their critical care management from November 1, 2003 until July 31, 2007. All PDTs were performed under bronchoscopic guidance. After PDT, we reviewed the immediate post-procedural films to assess the utility of routine postoperative CXR. For the purposes of CXR review, we considered a procedure to be either uncomplicated or technically difficult. Clinically relevant CXR findings were new barotrauma (pneumothorax, pneumomediastinum) or a significant change in consolidation from the pre-procedure film.

RESULTS

A total of 384 patients underwent PDT during the study period. Of these, 345 had immediate post-procedural CXRs available for review. There were 252 PDTs (73%) documented as uncomplicated. There were 93 (27%) technically difficult procedures, with 107 adverse events recorded. In 82 (24%) procedures, these difficulties were described as minor procedural complications [multiple attempts at needle insertion (> or = 3), minor bleeding or tracheal ring fracture]. Significant complications (mal-placement in the anterior mediastinum and major bleeding) were documented in 12 (3.5%) patients. New abnormalities were noted on 8 (2.3%) immediate post-procedural CXRs. In only one patient was there a new CXR change in an uncomplicated PDT.

CONCLUSIONS

Immediate CXR after uncomplicated PDT performed under bronchoscopic guidance rarely reveals unexpected radiological abnormalities. The role of CXR after PDT appears to be restricted to those patients undergoing technically difficult and complicated procedures. A change in practice to this effect will lead to reductions in both medical costs and exposure of staff and patients to ionizing radiation.

Head and neck cancer waiting times

The guidelines for treating cancer changed in December 2005 to no longer than 62 days from urgent referral to treatment, or 31 days from diagnosis to treatment. The use, by general practitioners, of suspected head and neck cancer proformas has reduced the time taken from referral to first outpatient appointment from 15 days in 2003 to 5.5 days in 2005. The introduction of specific radiology request forms for suspected malignancy has allowed easier identification of requests for imaging and subsequently a shorter waiting time for radiological investigations from 23 days in 2003 to 10 days in 2005. The appointment of a new dedicated head and neck cancer consultant at Aintree and the provision of another linear accelerator have reduced the waiting time for surgery from 68 days in 2003 to 39 days in 2005 and radiotherapy from 86 days in 2003 to 52.6 days in 2005. Patients not referred as suspected cancer patients who subsequently receive primary radiotherapy for a head and neck cancer fall outside the 62 day rule, being treated on average 70 days after referral.

In vitro metabolism of the epoxide substructure of cryptophycins by cytosolic glutathione S-transferase: species differences and stereoselectivity

The enzyme kinetics of the glutathione (GSH) conjugation of cryptophycin 52 (C52, R-stereoisomer) and cryptophycin 53 (C53, S-stereoisomer) by cytosolic glutathione S-transferases (cGSTs) from human, rat, mouse, dog and monkey liver were studied. Vmax, Km, and CLint values for glutathione conjugation of C52 (R-stereoisomer) were 0.10 +/- 0.01 nmol min-1 mg-1, 3.24 +/- 0.23 microM, and (3.15 +/- 0.09) x 10(-2) ml min-1 mg-1, respectively, in human cytosol. Due to limited solubility relative to the Km, only CLint values were determined in rat ((7.76 +/- 0.10) x 10-2 ml min-1 mg-1) and mouse ((7.61 +/- 0.50) x 10(-2) ml min-1 mg-1) cytosol. Enzyme kinetic parameters could not be determined for C53 (S-stereoisomer). Microsomal GSH conjugation in human, rat, and mouse was attributed to cytosolic contamination. No GSH conjugation was seen in any biological matrix from dog or monkey. There was little GSH conjugation of C53 by cytosol or microsomes from any species. The metabolism of C52 and C53 by epoxide hydrolase was also investigated. No diol product was observed in any biological matrix from any species. Thus, cGSTs are primarily responsible for C52 metabolism.

Acoustic parameters of snoring sound to compare natural snores with snores during 'steady-state' propofol sedation

OBJECTIVES

To investigate the acoustic similarity between natural and sedation-induced snores.

DESIGN

Prospective observational study.

SETTING

University Hospital Aintree, Liverpool, UK.

PARTICIPANTS

Twenty-one patients, who had already had overnight snore recordings, completed a pre-operative sleep nasendoscopic examination. Endoscopic examination of the upper aero-digestive tract was performed at sequentially increasing, steady-state sedation levels, using intravenous propofol administered according to a weight/time-based algorithm to predict blood and effect site (tissue) concentrations. At each sedation level at which snoring occurred, snoring sound was recorded. From these samples, snore files, comprising the inspiratory sound of each snore were created. Similarly, from natural snores recorded pre-operatively, snore files, comprising the inspiratory sounds of the first 100 snores with the patient sleeping in a supine position, were also created.

MAIN OUTCOME MEASURES

Snore duration (s), loudness (dBA), periodicity (%) and energy ratios for the frequency sub-bands 0-200, 0-250 and 0-400 Hz.

RESULTS

Snore loudness increased significantly (P < 0.0001), whilst energy ratios for frequency bands 0-200, 0-250 and 0-400 Hz all decreased significantly as sedation level increased (P < 0.001). A significant difference between natural snoring and snoring induced at the lowest sedation level was shown (P < 0.0001). Endoscopic examination was not tolerated at this sedation level.

CONCLUSIONS

The acoustic characteristics of sedation-induced and natural snores are sufficiently different to recommend the need for further research to determine whether the technique of sleep nasendoscopy is, in fact, a valid predictor of outcome of snoring surgery.

Snoring Surgery: A Retrospective Review

OBJECTIVE

To undertake a retrospective, questionnaire review of surgery for heavy snoring, to ascertain patients' perception of the procedure and its effect on their snoring.

PATIENTS AND METHODS

A specifically designed postal questionnaire was sent to 261 patients who underwent snoring surgery at University Hospital Aintree, Liverpool, UK, between April 1993 and March 2000. One hundred ninety-three patients responded (73.9%), including 151 men and 42 women. Mean age was 49.0 years (range, 24-74 yrs).

RESULTS

Twenty-two patients had a uvulopalatopharyngoplasty, 53 a traditional laser palatoplasty and uvulectomy, and 118 an uvulopalatal elevation palatoplasty. There was a 26% patient-reported postoperative infection rate. Morbidity regarding postoperative swallowing, pharyngeal sensation or voice change appeared minimal. Seventy-six percent scored postoperative pain as "moderate" or "severe," irrespective of the operation performed (P = 0.989). Thirty-seven percent of patients perceived an improvement in postoperative sleep quality. Twenty-four percent of patients reported no improvement in snoring after surgery. Forty-three percent reported an initial improvement that was not sustained for 2 years, whereas 34% of patients benefited from an improvement sustained for longer than 2 years, irrespective of the operation performed (P = 0.143). Only 47%, with hindsight, would have undergone surgery.

CONCLUSION

These data highlight that snoring surgery has a high postoperative morbidity rate and a high failure rate. Research endeavors should be directed to the development of a strategy which enables reliable preoperative identification of patients' who enjoy sustained benefit postoperatively.

Percutaneous cervical pharyngostomy: a traditional technique revisited

Enteral tube feeding is widely used in intensive care units, high dependency units and general wards. In some patients, an adequate intake is not maintained because patients cannot tolerate the tube. Insertion of an enteral feeding tube via a pharyngostomy is simple and potentially more easily tolerated. We describe our experience with three critically ill patients, using disposable vascular access equipment and a dilational technique. All three patients received markedly increased nutrition, but one patient suffered haemorrhagic complications.

Conservative management of epistaxis: are we putting patients at risk of developing venous thromboembolic complications?

A retrospective study of 1585 patients, admitted with epistaxis to a busy District General Hospital in the United Kingdom between 1990 and 2000, was undertaken in order to identify the relationship between hospital admission for epistaxis and the development of a venous thromboembolic event. Only one person (0.06%) developed pulmonary embolus (PE) within 6 weeks of hospital admission. No one developed a deep vein thrombosis (DVT). This compares with the incidence of DVT and fatal PE in the general population. In our study population, the incidence of both PE and DVT was found to be no greater than that seen within the community and certainly less than the incidence seen within a group of high risk hospitalised patients. We conclude that hospital admission for epistaxis does not place the patient at increased risk of thromboembolic disease.

Acoustic analysis of snoring before and after palatal surgery

To investigate the effectiveness of palatal surgery for nonapnoeic snoring, 35 patients were block randomised to undergo one of two different palatoplasty procedures. Patients were admitted pre-operatively for audio recording of snoring sound and video recording of sleeping position, and between 1.0 and 4.1 months (mean 2.5) and between 5.9 and 17.5 months (mean 9.7) post-operatively. Sound files, comprising the inspiratory sound of the first 100 snores whilst sleeping in a supine position, were analysed using specifically designed software. Snore duration (s), loudness (dBA), periodicity (%) and energy ratios for the frequency bands 0-200 Hz, 0-250 Hz and 0-400 Hz were calculated. Subjective outcomes were noted. Operation type, body mass index, age, peak nasal inspiratory flow rate, Epworth sleep score and alcohol intake were considered as confounding variables. No patient was cured from snoring. Paired t-test analysis demonstrated statistically significant changes between pre- and early post-operative recordings for snore periodicity and energy ratios in the frequency ranges 0-200 Hz, 0-250 Hz and 0-400 Hz. In conclusion, only the 0-250-Hz energy ratio measurements maintained a statistically significant improvement at the time of the late post-operative recording, despite an obvious drift back to pre-operative levels. No confounding variables were identified. The subjective and objective results correlated poorly. Post-operative changes in the acoustic parameters of snoring sound, following palatal surgery, are demonstrable but short-lived.