Utilizing vancomycin as secondary prophylaxis for the prevention of recurrent Clostridioides difficile infection

Background: Recurrent Clostridioides difficile infection (CDI) is associated with significant morbidity, mortality, and healthcare-related costs. Although data are minimal, agents including oral vancomycin have been used as secondary prophylaxis to prevent recurrent CDI. Methods: We conducted a randomized, double-blind, placebo-controlled trial to determine the effectiveness of vancomycin at preventing CDI from October 2019 to September 2022. Eligible patients had a history of at least 1 episode of CDI and were receiving systemic antibiotics for another condition. Participants were randomized 1:1 to oral vancomycin 125 mg by mouth twice daily and were interviewed at 1, 2, and 3 months thereafter to assess recurrence. We enrolled 26 patients: 15 completed the 1-month interview, 12 completed the 2-month interview, and 11 completed the full study. Those 15 participants who did not complete the 3-month interview were considered dropouts. The final sample for this study included those 11 participants who completed all interviews. Demographics and outcomes are shown in Table 1. Results: One case of recurrent CDI was reported at the 1-month interview and a second was reported at 3 months; both cases had received the placebo. The study was terminated early due to low enrollment. Conclusions: Although our results did not reach statistical significance and this study was limited in small sample size, our findings suggest that secondary prophylaxis with oral vancomycin may be beneficial in patients who are actively receiving antibiotics, which is consistent with prior retrospective studies. Future studies with larger sample sizes are still needed to examine this important question of whether secondary prophylaxis is useful for preventing recurrent CDI

Review of methods for measuring β-cell function: Design considerations from the Restoring Insulin Secretion (RISE) Consortium

The Restoring Insulin Secretion (RISE) study was initiated to evaluate interventions to slow or reverse the progression of β-cell failure in type 2 diabetes (T2D). To design the RISE study, we undertook an evaluation of methods for measurement of β-cell function and changes in β-cell function in response to interventions. In the present paper, we review approaches for measurement of β-cell function, focusing on methodologic and feasibility considerations. Methodologic considerations included: (1) the utility of each technique for evaluating key aspects of β-cell function (first- and second-phase insulin secretion, maximum insulin secretion, glucose sensitivity, incretin effects) and (2) tactics for incorporating a measurement of insulin sensitivity in order to adjust insulin secretion measures for insulin sensitivity appropriately. Of particular concern were the capacity to measure β-cell function accurately in those with poor function, as is seen in established T2D, and the capacity of each method for demonstrating treatment-induced changes in β-cell function. Feasibility considerations included: staff burden, including time and required methodological expertise; participant burden, including time and number of study visits; and ease of standardizing methods across a multicentre consortium. After this evaluation, we selected a 2-day measurement procedure, combining a 3-hour 75-g oral glucose tolerance test and a 2-stage hyperglycaemic clamp procedure, augmented with arginine

T2MR: A New Tool for Anti-Fungal Stewardshi

Background: Candidemia is associated with mortality rates between 30 and 50%. T2 magnetic resonance assay (T2MR) is a costly, rapid diagnostic technology that can detect the five most common Candida species in blood with a sensitivity of 91% and specificity of 99.4%. The clinical role of this tool remains unclear but this study shares our clinical experience with T2MR. Methods: We conducted a retrospective chart review of patients with T2MR testing performed from April 25, 2017 through April 25, 2018. T2MR ordering was restricted to Infectious Diseases pharmacists and physicians without specific ordering criteria. Variables cataloged included the time between order and result in the medical chart, T2MR result, anti-fungal therapy and duration. Descriptive statistics were reported on collected variables. Results: Sixty-eight unique patients had T2MR ordered at least once during the study time period. The median age was 62.5 years (interquartile range (IQR), 22–92) and 42 patients (62%) were male. The median time between order and result appearing in the medical chart was 6.21 hours (IQR, 3.55–40.93). Out of 72 tests performed, 4 were positive (2 for C. parapsilosis and 2 for C. krusei/glabrata). Only 1 of 4 T2MR positive patients had concurrent candidemia while 1 patient had suspected fungal endophthalmitis, 1 patient was managed for a fistula, and 1 patient had cutaneous candidiasis. Of the negative tests, 1 patient had a false negative T2MR result despite blood cultures growing C. glabrata. There was only 1 invalid test in our sample. Thirty-six patients were initiated or maintained on anti-fungal therapy at the time of the T2MR test, with micafungin being the most commonly prescribed anti-fungal agent. Negative T2MR patients had a median anti-fungal therapy duration of 2 days (IQR, 0–16). Sixteen patients (44%) had their anti-fungal therapy discontinued within 1 day of the negative T2MR result. There were no patients with a negative T2MR result who subsequently developed candidemia within 30 days after T2MR testing. Conclusion: Our study showcases the benefit seen with T2MR in curtailing unnecessary anti-fungal exposure. Study limitations include a small cohort and evaluation at a single center. There is an opportunity for this technology to be utilized in anti-fungal stewardship

T2MR: A New Tool for Anti-Fungal Stewardshi

Background: Candidemia is associated with mortality rates between 30 and 50%. T2 magnetic resonance assay (T2MR) is a costly, rapid diagnostic technology that can detect the five most common Candida species in blood with a sensitivity of 91% and specificity of 99.4%. The clinical role of this tool remains unclear but this study shares our clinical experience with T2MR. Methods: We conducted a retrospective chart review of patients with T2MR testing performed from April 25, 2017 through April 25, 2018. T2MR ordering was restricted to Infectious Diseases pharmacists and physicians without specific ordering criteria. Variables cataloged included the time between order and result in the medical chart, T2MR result, anti-fungal therapy and duration. Descriptive statistics were reported on collected variables. Results: Sixty-eight unique patients had T2MR ordered at least once during the study time period. The median age was 62.5 years (interquartile range (IQR), 22–92) and 42 patients (62%) were male. The median time between order and result appearing in the medical chart was 6.21 hours (IQR, 3.55–40.93). Out of 72 tests performed, 4 were positive (2 for C. parapsilosis and 2 for C. krusei/glabrata). Only 1 of 4 T2MR positive patients had concurrent candidemia while 1 patient had suspected fungal endophthalmitis, 1 patient was managed for a fistula, and 1 patient had cutaneous candidiasis. Of the negative tests, 1 patient had a false negative T2MR result despite blood cultures growing C. glabrata. There was only 1 invalid test in our sample. Thirty-six patients were initiated or maintained on anti-fungal therapy at the time of the T2MR test, with micafungin being the most commonly prescribed anti-fungal agent. Negative T2MR patients had a median anti-fungal therapy duration of 2 days (IQR, 0–16). Sixteen patients (44%) had their anti-fungal therapy discontinued within 1 day of the negative T2MR result. There were no patients with a negative T2MR result who subsequently developed candidemia within 30 days after T2MR testing. Conclusion: Our study showcases the benefit seen with T2MR in curtailing unnecessary anti-fungal exposure. Study limitations include a small cohort and evaluation at a single center. There is an opportunity for this technology to be utilized in anti-fungal stewardship

Adverse Events Releated to Antibiotic Use in Patients with Myasthenia Gravis

Background: Myasthenia gravis is a medical condition involving the neuromuscular junction, characterized by weakness and fatigue of voluntary muscles. While the understanding of myasthenia gravis has progressed over the years, questions remain regarding which antimicrobial agents can be administered safely to these patients. Traditionally, aminoglycosides and fluoroquinolones have been avoided in this patient population, while other antimicrobials may be prescribed with caution. With minimal literature to guide practice, our aim was to review antimicrobial prescribing in patients with myasthenia gravis at our institution. Methods: We conducted a retrospective chart review of adult patients 18 years of age and older with a diagnosis of myasthenia gravis who were admitted from January 2012 through December 2015. Charts were reviewed for the receipt of any antimicrobial during the course of hospitalization and any adverse events related to receipt of antimicrobial agents. Results: 205 patients with a diagnosis of myasthenia gravis were admitted to our institution during the study period. 132 (64.4 %) patients were female and ages ranged from 20 to 98 with a median age of 59 years. 159 (77.6 %) patients received at least 1 dose of an antimicrobial agent during their hospitalization. It was notable that 12.2 % and 11.7 % of patients received at least 1 dose of ciprofloxacin or levofloxacin, respectively. Additionally, 3.9 % of patients received at least 1 dose of an aminoglycoside (gentamicin or tobramycin). Five patients experienced a worsening of their myasthenia gravis symptoms with antibiotic use; 2 cases involved levofloxacin and 1 case each involved ciprofloxacin, cefazolin, or clindamycin. Of note, the average duration of therapy prior to symptoms being noted was 2.6 days. Conclusion: This study highlights the wide variation in antimicrobial prescribing for patients with myasthenia gravis. Our chart review identified few adverse reactions exacerbating disease symptoms related to antimicrobial use. As it is still unclear the exact mechanism for the development of reactions in select patients with myasthenia gravis, further research may be needed to elucidate this information

Adverse Events Releated to Antibiotic Use in Patients with Myasthenia Gravis

Background: Myasthenia gravis is a medical condition involving the neuromuscular junction, characterized by weakness and fatigue of voluntary muscles. While the understanding of myasthenia gravis has progressed over the years, questions remain regarding which antimicrobial agents can be administered safely to these patients. Traditionally, aminoglycosides and fluoroquinolones have been avoided in this patient population, while other antimicrobials may be prescribed with caution. With minimal literature to guide practice, our aim was to review antimicrobial prescribing in patients with myasthenia gravis at our institution. Methods: We conducted a retrospective chart review of adult patients 18 years of age and older with a diagnosis of myasthenia gravis who were admitted from January 2012 through December 2015. Charts were reviewed for the receipt of any antimicrobial during the course of hospitalization and any adverse events related to receipt of antimicrobial agents. Results: 205 patients with a diagnosis of myasthenia gravis were admitted to our institution during the study period. 132 (64.4 %) patients were female and ages ranged from 20 to 98 with a median age of 59 years. 159 (77.6 %) patients received at least 1 dose of an antimicrobial agent during their hospitalization. It was notable that 12.2 % and 11.7 % of patients received at least 1 dose of ciprofloxacin or levofloxacin, respectively. Additionally, 3.9 % of patients received at least 1 dose of an aminoglycoside (gentamicin or tobramycin). Five patients experienced a worsening of their myasthenia gravis symptoms with antibiotic use; 2 cases involved levofloxacin and 1 case each involved ciprofloxacin, cefazolin, or clindamycin. Of note, the average duration of therapy prior to symptoms being noted was 2.6 days. Conclusion: This study highlights the wide variation in antimicrobial prescribing for patients with myasthenia gravis. Our chart review identified few adverse reactions exacerbating disease symptoms related to antimicrobial use. As it is still unclear the exact mechanism for the development of reactions in select patients with myasthenia gravis, further research may be needed to elucidate this information

Evaluation of anuran diversity and success in tertiary wastewater treatment wetlands

Constructed wetlands (CWs) are a multifunctional environmental technology capable of supporting plant and wildlife communities and removing excess nutrients and other pollutants. Tertiary treatment wetlands have also been proposed as one solution to remove persistent pharmaceuticals and personal care products (PPCPs) that remain after conventional wastewater treatment. Though aquatic wildlife is generally sensitive to environmental contaminants, it is unknown whether CWs can serve dual purposes supporting wildlife habitat and polishing wastewater. Our objective was to assess the capacity of a newly established CW for tertiary wastewater treatment to support amphibians. Specifically, we assessed adult anuran occupancy and tadpole and adult body size and condition relative to nearby unimpacted ponds. We found that a diverse community of adult anurans rapidly colonized the wetlands where successful reproduction was documented. Adult frogs and tadpoles were observed to have variable sizes among ponds with some life stages in better body condition at the tertiary treatment wetlands. Preliminary investigations suggest that tertiary treatment wetlands provide habitat for successful colonization and reproduction of anurans, but carryover effects need to be evaluated to determine if tertiary treatment wetlands serve as sinks or suitable habitat that supports stable populations

Thinking Outside the Bowel: Clostridium difficile Bacteremia Case Series

Background: While Clostridium difficile gastrointestinal infection (CDI) is the most common hospital-acquired infectious disease, C. difficile bacteremia (CDB) is exceedingly rare and its risk factors, mortality rate, and modalities of treatment are not well defined. Methods: We conducted a retrospective, IRB approved, chart review of adult patients with a diagnosis of CDB admitted to our institutions from 2011 through 2017. Variables catalogued included previous antibiotic and proton pump inhibitor (PPI) use, co-morbid conditions, prior history of CDI, diarrhea at the time of CDB, active malignancy, and gastrointestinal (GI) disruption (e.g., perforated viscous, GI bleeding, abdominal malignancy). Treatment courses and outcomes for CDB were also gleaned. Results: Seven patients with CDB were identified, with ages ranging from 35 to 81 years (median 65 years). Six (85.7%) patients had evidence of GI disruption and three (42.9%) were noted to have active cancer. Three (42.9%) patients had previous CDI by testing and three (42.9%) had complaints of diarrhea at the time of diagnosis. Six (85.7%) patients had exposure to PPIs before CDB diagnosis, and five (71.4%) had prior antibiotic exposure in the past 30 days. Five (71.4%) patients had a polymicrobial bloodstream infection, with the majority of organisms being enteric in nature. In terms of CDB treatment, the majority of patients received intravenous (IV) metronidazole and/or IV vancomycin in addition to broad-spectrum antibiotics due to the polymicrobial nature of their infection. Three (42.9%) patients died during their hospitalization, only one who had polymicrobial bacteremia. Conclusion: CDI is the most common cause of hospital acquired infection, although rarely causes bacteremia. Notable findings in our population included older age, concomitant malignancy, evidence of GI disruption, and prior exposure to PPIs and antibiotics. Antibiotics chosen to treat CDB were IV metronidazole and/or IV vancomycin, with other broad-spectrum antibiotics utilized due to polymicrobial bacteremia. CDB is associated with a high mortality rate and is commonly manifested as a polymicrobial bloodstream infection. This is one of the larger case series that adds to the scant literature characterizing patients diagnosed with CDB