Impact of direct disk-diffusion testing on time to optimal antibiotic therapy

We evaluated the impact of preliminary blood-culture antibiotic susceptibility testing on time to optimal antibiotic therapy in a cohort of 503 patients with monomicrobial bloodstream infections. The median time from blood-culture collection to optimal antibiotics was 17 hours earlier in the preliminary antibiotic susceptibility testing group

The Population Dynamics of Antibiotic Resistance in Staphylococcus aureus in Boston: A Return to Antibiotic Susceptibility

Abstract Background: Methicillin resistant Staphylococcus aureus (MRSA) has been declining over the past decade, but changes in S. aureus overall and the implications for trends in antibiotic resistance remain unclear. We determine whether the decline in rates of infection by MRSA has been accompanied by changes in rates of infection by methicillin susceptible, penicillin resistant S. aureus (MSSA) and penicillin susceptible S. aureus (PSSA). We test if these dynamics are associated with specific genetic lineages and evaluate gains and losses of resistance at the strain level. Methods: We conducted a 15 year retrospective observational study at two tertiary care institutions in Boston, MA of 31,589 adult inpatients with S. aureus infections. Surveillance swabs and duplicate specimens were excluded. We also sequenced a sample of contemporary isolates (n = 180) obtained between January 2016 and July 2016. We determined changes in the annual rates of infection per 1,000 inpatient admissions by S. aureus subtype and in the annual mean antibiotic resistance by subtype. We performed phylogenetic analysis to generate a population structure and infer gain and loss of the genetic determinants of resistance. Results: Of the 43,954 S. aureus infections over the study period, 21,779 were MRSA, 17,565 MSSA and 4,610 PSSA. After multivariate adjustment, annual rates of infection by S. aureus declined from to 2014 by 2.9% (95% confidence interval (CI), 1.6%–4.3%), attributable to an annual decline in MRSA of 9.1% (95% CI, 6.3%–11.9%) and in MSSA by 2.2% (95% CI, 0.4%–4.0%). PSSA increased over this time period by 4.6% (95% CI, 3.0%–6.3%) annually. Resistance in S. aureus decreased from 2000 to 2014 by 0.86 antibiotics (95% CI, 0.81–0.91). By phylogenetic inference, 5/35 MSSA and 2/20 PSSA isolates in the common MRSA lineages ST5/USA100 and ST8/USA300 arose from the loss of genes conferring resistance. Conclusion: At two large tertiary care centers in Boston, S. aureus infections have decreased in rate and have become more susceptible to antibiotics, with a rise in PSSA making penicillin an increasingly viable and important treatment option. Disclosures All authors: No reported disclosures

National Mass Drug Administration Costs for Lymphatic Filariasis Elimination

Lymphatic filariasis (LF), commonly known as elephantiasis, is a profoundly disfiguring parasitic disease caused by thread-like nematode worms. This disease can often be disabling, thus reducing the potential productivity of the affected individuals. The WHO places the number of people at risk in 83 countries at 1.307 billion. This study was undertaken in seven countries—Burkina Faso, Ghana, Egypt, Tanzania, the Philippines, the Dominican Republic, and Haiti—using a common protocol to determine the costs of mass drug administration (MDA) programs to interrupt transmission of infection with LF, because there is lack of sufficient information about the costs of these programs. The results demonstrate that LF MDA is affordable and relatively inexpensive when compared to other public health programs. In the context of initiatives for integrating programs for the control and elimination of neglected tropical diseases, this study adds specifically to the relatively scarce body of information about the costs of MDA programs for LF. It also adds to the general knowledge about the application of methods that can be used to estimate the costs and cost-effectiveness of an integrated approach

Treatment Policy Learning in Multiobjective Settings with Fully Observed Outcomes

© 2020 Owner/Author. In several medical decision-making problems, such as antibiotic prescription, laboratory testing can provide precise indications for how a patient will respond to different treatment options. This enables us to "fully observe" all potential treatment outcomes, but while present in historical data, these results are infeasible to produce in real-time at the point of the initial treatment decision. Moreover, treatment policies in these settings often need to trade off between multiple competing objectives, such as effectiveness of treatment and harmful side effects. We present, compare, and evaluate three approaches for learning individualized treatment policies in this setting: First, we consider two indirect approaches, which use predictive models of treatment response to construct policies optimal for different trade-offs between objectives. Second, we consider a direct approach that constructs such a set of policies without intermediate models of outcomes. Using a medical dataset of Urinary Tract Infection (UTI) patients, we show that all approaches learn policies that achieve strictly better performance on all outcomes than clinicians, while also trading off between different objectives. We demonstrate additional benefits of the direct approach, including flexibly incorporating other goals such as deferral to physicians on simple cases

A Systems Biology Approach To Modeling Vibrio cholerae Gene Expression under Virulence-Inducing Conditions▿

Vibrio cholerae is a Gram-negative bacillus that is the causative agent of cholera. Pathogenesis in vivo occurs through a series of spatiotemporally controlled events under the control of a gene cascade termed the ToxR regulon. Major genes in the ToxR regulon include the master regulators toxRS and tcpPH, the downstream regulator toxT, and virulence factors, the ctxAB and tcpA operons. Our current understanding of the dynamics of virulence gene expression is limited to microarray analyses of expression at selected time points. To better understand this process, we utilized a systems biology approach to examine the temporal regulation of gene expression in El Tor V. cholerae grown under virulence-inducing conditions in vitro (AKI medium), using high-resolution time series genomic profiling. Results showed that overall gene expression in AKI medium mimics that of in vivo studies but with less clear temporal separation between upstream regulators and downstream targets. Expression of toxRS was unaffected by growth under virulence-inducing conditions, but expression of toxT was activated shortly after switching from stationary to aerating conditions. The tcpA operon was also activated early during mid-exponential-phase growth, while the ctxAB operon was turned on later, after the rise in toxT expression. Expression of ctxAB continued to rise despite an eventual decrease in toxT. Cluster analysis of gene expression highlighted 15 hypothetical genes and six genes related to environmental information processing that represent potential new members of the ToxR regulon. This study applies systems biology tools to analysis of gene expression of V. cholerae in vitro and provides an important comparator for future studies done in vivo

Analysis of multiple bacterial species and antibiotic classes reveals large variation in the association between seasonal antibiotic use and resistance.

Understanding how antibiotic use drives resistance is crucial for guiding effective strategies to limit the spread of resistance, but the use-resistance relationship across pathogens and antibiotics remains unclear. We applied sinusoidal models to evaluate the seasonal use-resistance relationship across 3 species (Staphylococcus aureus, Escherichia coli, and Klebsiella pneumoniae) and 5 antibiotic classes (penicillins, macrolides, quinolones, tetracyclines, and nitrofurans) in Boston, Massachusetts. Outpatient use of all 5 classes and resistance in inpatient and outpatient isolates in 9 of 15 species-antibiotic combinations showed statistically significant amplitudes of seasonality (false discovery rate (FDR) < 0.05). While seasonal peaks in use varied by class, resistance in all 9 species-antibiotic combinations peaked in the winter and spring. The correlations between seasonal use and resistance thus varied widely, with resistance to all antibiotic classes being most positively correlated with use of the winter peaking classes (penicillins and macrolides). These findings challenge the simple model of antibiotic use independently selecting for resistance and suggest that stewardship strategies will not be equally effective across all species and antibiotics. Rather, seasonal selection for resistance across multiple antibiotic classes may be dominated by use of the most highly prescribed antibiotic classes, penicillins and macrolides

Trends in Antibiotic Susceptibility in Staphylococcus aureus in Boston, Massachusetts, from 2000 to 2014

ABSTRACT The rate of infection by methicillin-resistant Staphylococcus aureus (MRSA) has declined over the past decade, but it is unclear whether this represents a decline in S. aureus infections overall. To evaluate the trends in the annual rates of infection by S. aureus subtypes and mean antibiotic resistance, we conducted a 15-year retrospective observational study at two tertiary care institutions in Boston, MA, of 31,753 adult inpatients with S. aureus isolated from clinical specimens. We inferred the gain and loss of methicillin resistance through genome sequencing of 180 isolates from 2016. The annual rates of infection by S. aureus declined from 2003 to 2014 by 4.2% (2.7% to 5.6%), attributable to an annual decline in MRSA of 10.9% (9.3% to 12.6%). Penicillin-susceptible S. aureus (PSSA) increased by 6.1% (4.2% to 8.1%) annually, and rates of methicillin-susceptible penicillin-resistant S. aureus (MSSA) did not change. Resistance in S. aureus decreased from 2000 to 2014 by 0.8 antibiotics (0.7 to 0.8). Within common MRSA clonal complexes, 3/14 MSSA and 2/21 PSSA isolates arose from the loss of resistance-conferring genes. Overall, in two tertiary care institutions in Boston, MA, a decline in S. aureus infections has been accompanied by a shift toward increased antibiotic susceptibility. The rise in PSSA makes penicillin an increasingly viable treatment option

Effectiveness of interventions to promote screening for diabetic retinopathy.

ObjectiveTo assess the effectiveness of interventions aimed to increase retinal screening among people with diabetes.MethodsA systematic literature search was conducted of multiple electronic bibliographic databases up to May 2005. Studies were included if interventions were used to promote screening for diabetic retinopathy in any language and with any study design.ResultsForty-eight studies (12 randomized controlled trials [RCTs], four nonrandomized studies, and 32 pre-post studies) with a total of 162,157 participants, examined a wide range of interventions, which focused on one or more of the following: (1) patients or populations, (2) providers or practices, and (3) healthcare system infrastructure and processes. Four of five RCTs focusing on patients demonstrated that interventions increased screening significantly, with relative risk ranging from 1.05 (95% confidence interval [CI]=1.01-1.08) to 2.01 (95% CI=1.48-2.73). Five RCTs with a focus on the system all demonstrated significant increases in screening with relative risk ranging from 1.12 (95% CI=1.03-1.22) to 5.56 (95% CI=2.19-14.10). Thirty-six non-RCTs, which included interventions with single or multiple foci, also generally demonstrated positive effects.ConclusionsIncreasing patient awareness of diabetic retinopathy, improving provider and practice performance, and improving healthcare system infrastructure and processes, can significantly increase screening for diabetic retinopathy. Further research should explore strategies for increasing the rate of retinal screening among diverse or disadvantaged populations and the economic efficiency of effective interventions in large community populations