Macrolide‐resistant Mycoplasma pneumoniae pneumonia in transplantation: Increasingly typical?

Mycoplasma pneumoniae is one of the most common bacterial causes of pneumonia. Macrolide‐resistant M pneumoniae (MRMP) was documented in 7.5% of isolates in the United States. Resistance portends poor outcomes to macrolide therapy, yet patients respond well to fluoroquinolones or tetracyclines such as minocycline. However, MRMP may be under‐appreciated because M pneumoniae generally causes relatively mild infections in non‐immunosuppressed adults that may resolve without effective therapy and because microbiological confirmation and susceptibility are not routinely performed. We report two cases of pneumonia due to MRMP in kidney transplant recipients. Both patients required hospital admission, worsened on macrolide therapy, and rapidly defervesced on doxycycline or levofloxacin. In one case, M pneumoniae was only identified by multiplex respiratory pathogen panel analysis of BAL fluid. Macrolide resistance was confirmed in both cases by real‐time PCR and point mutations associated with macrolide resistance were identified. M pneumoniae was isolated from both cases, and molecular genotyping revealed the same genotype. In conclusion, clinicians should be aware of the potential for macrolide resistance in M pneumoniae, and may consider non‐macrolide‐based therapy for confirmed or non‐responding infections in patients who are immunocompromised or hospitalized.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163484/2/tid13318.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163484/1/tid13318_am.pd

Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter With Appropriateness and Complications

Importance: Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm. Objective: To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device use and fewer complications. Design, Setting, and Participants: This cohort study of 21 653 PICCs placed for a primary indication of intravenous antimicrobial therapy between January 1, 2015, and July 26, 2019, was conducted in 42 hospitals participating in a quality collaborative across Michigan among hospitalized medical patients. Main Outcomes and Measures: Appropriateness of PICCs was defined according to the Michigan Appropriateness Guide for Intravenous Catheters as a composite measure of (1) single-lumen catheter use, (2) avoiding use of PICCs for 5 days or less, and (3) avoiding use of PICCs for patients with chronic kidney disease (defined as an estimated glomerular filtration rate/min/1.73 m2). Complications related to PICCs included catheter occlusion, deep vein thrombosis, and central line-associated bloodstream infection. The association between infectious disease physician approval, device appropriateness, and catheter complications was assessed using multivariable models, adjusted for patient comorbidities and hospital clustering. Results were expressed as odds ratios with 95% CIs. Results: A total of 21 653 PICCs were placed for intravenous antimicrobials (11 960 PICCs were placed in men [55.2%]; median age, 64.5 years [interquartile range, 53.4-75.4 years]); 10 238 PICCs (47.3%) were approved by an infectious disease physician prior to placement. Compared with PICCs with no documented approval, PICCs with approval by an infectious disease physician were more likely to be appropriately used (72.7% [7446 of 10 238] appropriate with approval vs 45.4% [5180 of 11 415] appropriate without approval; odds ratio, 3.53; 95% CI, 3.29-3.79; P \u3c .001). Furthermore, approval was associated with lower odds of a PICC-related complication (6.5% [665 of 10 238] with approval vs 11.3% [1292 of 11 415] without approval; odds ratio, 0.55; 95% CI, 0.50-0.61). Conclusions and Relevance: This cohort study suggests that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications. Policies aimed at ensuring infectious disease physician approval prior to PICC placement for antimicrobials may improve patient safety

Evaluation of a needle disinfectant technique to reduce infection‐related hospitalisation after transrectal prostate biopsy

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/142074/1/bju13982_am.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/142074/2/bju13982.pd

Risk factors and outcomes associated with community-onset and hospital-acquired coinfection in patients hospitalized for coronavirus disease 2019 (COVID-19): A multihospital cohort study

BACKGROUND: We sought to determine the incidence of community-onset and hospital-acquired coinfection in patients hospitalized with coronavirus disease 2019 (COVID-19) and to evaluate associated predictors and outcomes. METHODS: In this multicenter retrospective cohort study of patients hospitalized for COVID-19 from March 2020 to August 2020 across 38 Michigan hospitals, we assessed prevalence, predictors, and outcomes of community-onset and hospital-acquired coinfections. In-hospital and 60-day mortality, readmission, discharge to long-term care facility (LTCF), and mechanical ventilation duration were assessed for patients with versus without coinfection. RESULTS: Of 2,205 patients with COVID-19, 141 (6.4%) had a coinfection: 3.0% community onset and 3.4% hospital acquired. Of patients without coinfection, 64.9% received antibiotics. Community-onset coinfection predictors included admission from an LTCF (OR, 3.98; 95% CI, 2.34-6.76; P \u3c .001) and admission to intensive care (OR, 4.34; 95% CI, 2.87-6.55; P \u3c .001). Hospital-acquired coinfection predictors included fever (OR, 2.46; 95% CI, 1.15-5.27; P = .02) and advanced respiratory support (OR, 40.72; 95% CI, 13.49-122.93; P \u3c .001). Patients with (vs without) community-onset coinfection had longer mechanical ventilation (OR, 3.31; 95% CI, 1.67-6.56; P = .001) and higher in-hospital mortality (OR, 1.90; 95% CI, 1.06-3.40; P = .03) and 60-day mortality (OR, 1.86; 95% CI, 1.05-3.29; P = .03). Patients with (vs without) hospital-acquired coinfection had higher discharge to LTCF (OR, 8.48; 95% CI, 3.30-21.76; P \u3c .001), in-hospital mortality (OR, 4.17; 95% CI, 2.37-7.33; P ≤ .001), and 60-day mortality (OR, 3.66; 95% CI, 2.11-6.33; P ≤ .001). CONCLUSION: Despite community-onset and hospital-acquired coinfection being uncommon, most patients hospitalized with COVID-19 received antibiotics. Admission from LTCF and to ICU were associated with increased risk of community-onset coinfection. Future studies should prospectively validate predictors of COVID-19 coinfection to facilitate the reduction of antibiotic use

EFFECT OF FLAVANOID RICH FRACTION OF CITRUS MEDICA LINN. (RUTACEA) ON ETHYLENE GLYCOL INDUCED UROLITHIASIS IN RATS.

Ethylene glycol (0.75% v/v p.o. in drinking water; 28 days) induced urolithiasis was used to study the protective effect of  flavanoid rich fraction of Citrus medica Linn. (FFCM)  at three dose level (320 µg/kg; 380 µg/kg; 440 µg/kg-  28 days; p.o.) in male wistar albino rats (250-300g; n=6/group).  Cystone (750 mg/kg; p.o.) was used as standard drug. After completion of treatment period of 28 days,  24 hr urine sample and blood were collected. Various physical parameters like body weight, diuresis, pH, kidneys weight (wet and dry) were measured. Various stone forming inhibitors (Magnesium and Citrate) and promoters (Oxalate, Calcium, Phosphate, Uric acid and Urea)  were analysed in urine, serum and kidney homogenate. Renal function test (BUN and Creatinine clearance), antioxidant parameters (MDA and Catalase) and crystalluria were also evaluated. FFCM at all dose level significantly prevented EG induced changes in calcium, inorganic phosphate, uric acid, oxalate, urea, citrate, magnesium level; creatinine clearance and oxidative stress. FFCM possess anti-lithiatic activity in experimentally induced urolithiatic model (Ethylene glycol model), that can be attributed to its diuretic action, decrease in promoters and increase in inhibitors level & antioxidant potential. Key words: Urolithiasis, Citrus medica Linn., Calcium oxalate, Ethylene glycol

Tiering drug-drug interaction alerts by severity increases compliance rates.

OBJECTIVE: Few data exist measuring the effect of differentiating drug-drug interaction (DDI) alerts in computerized provider order entry systems (CPOE) by level of severity ("tiering"). We sought to determine if rates of provider compliance with DDI alerts in the inpatient setting differed when a tiered presentation was implemented. DESIGN: We performed a retrospective analysis of alert log data on hospitalized patients at two academic medical centers during the period from 2/1/2004 through 2/1/2005. Both inpatient CPOE systems used the same DDI checking service, but one displayed alerts differentially by severity level (tiered presentation, including hard stops for the most severe alerts) while the other did not. Participants were adult inpatients who generated a DDI alert, and providers who wrote the orders. Alerts were presented during the order entry process, providing the clinician with the opportunity to change the patient's medication orders to avoid the interaction. MEASUREMENTS: Rate of compliance to alerts at a tiered site compared to a non-tiered site. RESULTS: We reviewed 71,350 alerts, of which 39,474 occurred at the non-tiered site and 31,876 at the tiered site. Compliance with DDI alerts was significantly higher at the site with tiered DDI alerts compared to the non-tiered site (29% vs. 10%, p < 0.001). At the tiered site, 100% of the most severe alerts were accepted, vs. only 34% at the non-tiered site; moderately severe alerts were also more likely to be accepted at the tiered site (29% vs. 10%). CONCLUSION: Tiered alerting by severity was associated with higher compliance rates of DDI alerts in the inpatient setting, and lack of tiering was associated with a high override rate of more severe alerts

Excess antibiotic duration in patients hospitalized with pneumonia: Amulti-hospital cohort study

Background: Despite national guidelines, patients with pneumonia often receive antibiotics for longer than recommended. Factors that influence excess treatment are unknown. Methods: Retrospective cohort study of patients with pneumonia at 48 hospitals participating in the Michigan Hospital Medicine Safety consortium from December 2015 through July 2017. Adult patients were included if they were admitted to a non-ICU medicine service with pneumonia (diagnosis confirmed by symptoms, antibiotic receipt, and radiographs). Patients who were pregnant or had severe immune-compromise, concomitant infections, or conditions requiring a longer antibiotic course were excluded. Patient data were abstracted from the medical record by trained nurses and appropriate antibiotic duration was calculated for each patient based on national guidelines. Ongoing stewardship activities were assessed via survey to stewardship teams. Factors associated with excess duration antibiotic therapy were evaluated using multivariable logistic generalized estimate equations models, adjusting for hospital clustering. Results: Of 5179 eligible patients, 3776 (72.9%) met inclusion criteria. 68.5% (2586/3776) received an excess duration of antibiotic therapy. Antibiotics prescribed at hospital discharge accounted for 94.3% (9055/9603 additional days) of excess duration. Factors associated with excess duration included: identification of a bacterial pathogen (OR 1.90, 95% CI 1.32, 2.75), more signs of pneumonia (hypoxemia, abnormal temperature, auscultator findings, leukocytosis; OR 1.18, 95% CI 1.06 to 1.31 per additional sign), and uncomplicated pneumonia (vs. complicated pneumonia [OR 0.38, 95% CI 0.28 to 0.50] or healthcare-associated pneumonia [0.44, 95% CI 0.33, 0.57]). Hospitals that incorporated stewardship recommendations into their order-entry systems (89.6%, 43/48) had fewer patients receive excess duration (69.7% vs. 81.4%, P\u3c 0.001). Variation in excess antibiotic duration varied across the 48 hospitals (Figure), with no hospital performing well. Conclusions: Most hospitalized patients with pneumonia received an excess duration of antibiotic treatment. Although incorporating stewardship guidelines into order-entry may be one countermeasure, substantial improvement will require specifically targeting excessive antibiotic prescribing at hospital discharge