48 research outputs found
Influence of Antibiotic Exposure Intensity on the Risk of Clostridioides Difficile Infection
Antibiotics are a strong risk factor for Clostridioides difficile infection (CDI), and CDI incidence is often measured as an important outcome metric for antimicrobial stewardship interventions aiming to reduce antibiotic use. However, risk of CDI from antibiotics varies by agent and dependent on the intensity (i.e., spectrum and duration) of antibiotic therapy. Thus, the impact of stewardship interventions on CDI incidence is variable, and understanding this risk requires a more granular measure of intensity of therapy than traditionally used measures like days of therapy (DOT)
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Variation in Antibiotic Susceptibility of Uropathogens by Age among Ambulatory Pediatric Patients
We compared uropathogen antibiotic susceptibility across age groups of ambulatory
pediatric patients. For Escherichia coli (n=5,099) and other Gram-negative rods (n=626), significant
differences (p<0.05) existed across age groups for ampicillin, cefazolin, and
trimethoprim/sulfamethoxazole susceptibility. In E. coli, differences in
trimethoprim/sulfamethoxazole susceptibility varied from 79% in children under 2 to 88% in ages 16-18 (p<0.001) while ampicillin susceptibility varied from 30% in children under 2 to 53% in ages 2-5 (p=0.015). Uropathogen susceptibility to common urinary anti-infectives may be lower in the
youngest children. Further investigation into these differences is needed to facilitate appropriate and prudent treatment of urinary tract infections.This is an author's peer-reviewed final manuscript, as accepted by the publisher. The published article is copyrighted by Elsevier and can be found at: http://www.sciencedirect.com/science/journal/08825963
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Antimicrobial Use for Symptom Management in Patients Receiving Hospice and Palliative Care: A Systematic Review
BACKGROUND: Patients receiving hospice or palliative care often receive antimicrobial therapy; however the effectiveness
of antimicrobial therapy for symptom management in these patients is unknown.
OBJECTIVE: The study’s objective was to systematically review and summarize existing data on the prevalence and
effectiveness of antimicrobial therapy to improve symptom burden among hospice or palliative care patients.
DESIGN: Systematic review of articles on microbial use in hospice and palliative care patients published from
January 1, 2001 through June 30, 2011.
MEASUREMENTS: We extracted data on patients’ underlying chronic condition and health care setting, study
design, prevalence of antimicrobial use, whether symptom response following antimicrobial use was measured,
and the method for measuring symptom response.
RESULTS: Eleven studies met our inclusion criteria in which prevalence of antimicrobial use ranged from 4% to 84%.
Eight studies measured symptom response following antimicrobial therapy. Methods of symptom assessment
were highly variable and ranged from clinical assessment from patients’ charts to the Edmonton Symptom
Assessment Scale. Symptom improvement varied by indication, and patients with urinary tract infections (two
studies) appeared to experience the greatest improvement following antimicrobial therapy (range 67% to 92%).
CONCLUSION: Limited data are available on the use of antimicrobial therapy for symptom management among
patients receiving palliative or hospice care. Future studies should systematically measure symptom response
and control for important confounders to provide useful data to guide antimicrobial use in this population
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Risk of Acquiring Extended-Spectrum β-Lactamase–Producing Klebsiella Species and Escherichia coli from Prior Room Occupants in the Intensive Care Unit
OBJECTIVE. To quantify the association between admission to an intensive care unit (ICU) room most recently occupied by a patient positive for extended-spectrum beta-lactamase (EBSL)-producing gram-negative bacteria and acquisition of infection or colonization with that pathogen.
DESIGN. Retrospective cohort study.
SETTING AND PATIENTS. The study included patients admitted to medical and surgical ICUs of an academic medical center between September 1, 2001, and June 30, 2009.
METHODS. Perianal surveillance cultures were obtained at admission to the ICU, weekly, and at discharge from the ICU. Patients were included if they had culture results that were negative for ESBL-producing gram-negative bacteria at ICU admission and had an ICU length of stay longer than 48 hours. Pulsed-field gel electrophoresis (PFGE) was performed on ESBL-positive isolates from patients who acquired the same bacterial species (eg, Klebsiella species or Escherichia coli) as the previous room occupant.
RESULTS. Among 9,371 eligible admissions (7,651 unique patients), 267 (3%) involved patients who acquired an ESBL-producing pathogen in the ICU; of these patients, 32 (12%) were hospitalized in a room in which the prior occupant had been positive for ESBL. Logistic regression results suggested that the prior occupant's ESBL status was not significantly associated with acquisition of an ESBL-producing pathogen (adjusted odds ratio, 1.39 [95% confidence interval, 0.94-2.08]) after adjusting for colonization pressure and antibiotic exposure in the ICU. PFGE results suggested that 6 (18%) of 32 patients acquired a bacterial strain that was the same as or closely related to the strain obtained from the prior occupant.
CONCLUSIONS. These data suggest that environmental contamination may not play a substantial role in the transmission of ESBL-producing pathogens among ICU patients. Intensifying environmental decontamination may be less effective than other interventions in preventing transmission of ESBL-producing pathogens. Infect Control Hosp Epidemiol 2013;34(5):453-458Keywords: Enterobacteriaceae, Colonization pressure, Vancomycin resistant enterococci, Infection, Staphylococcus aureus, To patient transmission, Comorbidity index, Pneumoniae, Acquisition, Bacteri
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Use of electronic health record data to identify skin and soft tissue infections in primary care settings: a validation study
Background: Epidemiologic studies of skin and soft tissue infections (SSTIs) depend upon accurate case identification. Our objective was to evaluate the positive predictive value (PPV) of electronic medical record data for identification of SSTIs in a primary care setting. Methods: A validation study was conducted among primary care outpatients in an academic healthcare system. Encounters during four non-consecutive months in 2010 were included if any of the following were present in the electronic health record: International Classification of Diseases, Ninth Revision (ICD-9) code for an SSTI, Current Procedural Terminology (CPT) code for incision and drainage, or a positive wound culture. Detailed chart review was performed to establish presence and type of SSTI. PPVs and 95% confidence intervals (CI) were calculated among all encounters, initial encounters, and cellulitis/abscess cases. Results: Of the 731 encounters included, 514 (70.3%) were initial encounters and 448 (61.3%) were cellulitis/abscess cases. When the presence of an ICD-9 code, CPT code, or positive culture was used to identify SSTIs, 617 encounters were true positives, yielding a PPV of 84.4% [95% CI: 81.8–87.0%]. The PPV for using ICD-9 codes alone to identify SSTIs was 90.7% [95 % CI: 88.5–92.9%]. For encounters with cellulitis/abscess codes, the PPV was 91.5% [95% CI: 88.9–94.1%]. Conclusions: ICD-9 codes may be used to retrospectively identify SSTIs with a high PPV. Broadening SSTI case identification with microbiology data and CPT codes attenuates the PPV. Further work is needed to estimate the sensitivity of this method.Keywords: Skin infection, Positive predictive value, Methodologies, Abscess, Primary careKeywords: Skin infection, Positive predictive value, Methodologies, Abscess, Primary car
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Frequency of Outpatient Antibiotic Prescription on Discharge to Hospice Care
The use of antibiotics is common in hospice care despite limited evidence that it improves symptoms or quality of life. Patients
receiving antibiotics upon discharge from a hospital may be more likely to continue use following transition to hospice care despite
a shift in the goals of care. We quantified the frequency and characteristics for receiving a prescription for antibiotics on
discharge from acute care to hospice care. This was a cross-sectional study among adult inpatients (≥18 years old) discharged to
hospice care from Oregon Health & Science University (OHSU) from 1 January 2010 to 31 December 2012. Data were collected
from an electronic data repository and from the Department of Care Management. Among 62,792 discharges, 845 (1.3%) patients
were discharged directly to hospice care (60.0% home and 40.0% inpatient). Most patients discharged to hospice were >65
years old (50.9%) and male (54.6%) and had stayed in the hospital for ≤7 days (56.6%). The prevalence of antibiotic prescription
upon discharge to hospice was 21.1%. Among patients discharged with an antibiotic prescription, 70.8% had a documented infection
during their index admission. Among documented infections, 40.3% were bloodstream infections, septicemia, or endocarditis,
and 38.9% were pneumonia. Independent risk factors for receiving an antibiotic prescription were documented infection
during the index admission (adjusted odds ratio [AOR]=7.00; 95% confidence interval [95% CI]=4.68 to 10.46),
discharge to home hospice care (AOR=2.86; 95% CI=1.92 to 4.28), and having a cancer diagnosis (AOR=2.19; 95% CI=1.48
to 3.23). These data suggest that a high proportion of patients discharged from acute care to hospice care receive an antibiotic
prescription upon discharge
Risk Factors for Colonization with Extended-Spectrum β-Lactamase–producing Bacteria and Intensive Care Unit Admission
Coexisting conditions and previous antimicrobial drug exposure predict colonization
Impact of Empiric Antimicrobial Therapy on Outcomes in Patients with Escherichia coli and Klebsiella pneumoniae Bacteremia: A Cohort Study
<p>Abstract</p> <p>Background</p> <p>It is unclear whether appropriate empiric antimicrobial therapy improves outcomes in patients with bacteremia due to <it>Escherichia coli </it>or <it>Klebsiella</it>. The objective of this study is to assess the impact of appropriate empiric antimicrobial therapy on in-hospital mortality and post-infection length of stay in patients with <it>Escherichia coli </it>or <it>Klebsiella </it>bacteremia while adjusting for important confounding variables.</p> <p>Methods</p> <p>We performed a retrospective cohort study of adult patients with a positive blood culture for <it>E. coli </it>or <it>Klebsiella </it>between January 1, 2001 and June 8, 2005 and compared in-hospital mortality and post-infection length of stay between subjects who received appropriate and inappropriate empiric antimicrobial therapy. Empiric therapy was defined as the receipt of an antimicrobial agent between 8 hours before and 24 hours after the index blood culture was drawn and was considered appropriate if it included antimicrobials to which the specific isolate displayed <it>in vitro </it>susceptibility. Data were collected electronically and through chart review. Survival analysis was used to statistically assess the association between empiric antimicrobial therapy and outcome (mortality or length of stay). Multivariable Cox proportional hazards models were used to calculate hazard ratios (HR) and 95% confidence intervals (CI).</p> <p>Results</p> <p>Among 416 episodes of bacteremia, 305 (73.3%) patients received appropriate empiric antimicrobial therapy. Seventy-one (17%) patients died before discharge from the hospital. The receipt of appropriate antimicrobial agents was more common in hospital survivors than in those who died (p = 0.04). After controlling for confounding variables, there was no association between the receipt of appropriate empiric antimicrobial therapy and in-hospital mortality (HR, 1.03; 95% CI, 0.60 to 1.78). The median post-infection length of stay was 7 days. The receipt of appropriate antimicrobial agents was not associated with shortened post-infection length of stay, even after controlling for confounding (HR, 1.11; 95% CI 0.86 to 1.44).</p> <p>Conclusion</p> <p>Appropriate empiric antimicrobial therapy for <it>E. coli </it>and <it>Klebsiella </it>bacteremia is not associated with lower in-hospital mortality or shortened post-infection length of stay. This suggests that the choice of empiric antimicrobial agents may not improve outcomes and also provides data to support a randomized trial to test the hypothesis that use (and overuse) of broad-spectrum antibiotics prior to the availability of culture results is not warranted.</p
Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant Enterococci Co-colonization1
High prevalence of co-colonization increases risk for colonization or infection by vancomycin-resistant Staphylococcus aureus
Empiric Antibiotic Therapy for Staphylococcus aureus Bacteremia May Not Reduce In-Hospital Mortality: A Retrospective Cohort Study
Appropriate empiric therapy, antibiotic therapy with in vitro activity to the infecting organism given prior to confirmed culture results, may improve Staphylococcus aureus outcomes. We aimed to measure the clinical impact of appropriate empiric antibiotic therapy on mortality, while statistically adjusting for comorbidities, severity of illness and presence of virulence factors in the infecting strain.We conducted a retrospective cohort study of adult patients admitted to a tertiary-care facility from January 1, 2003 to June 30, 2007, who had S. aureus bacteremia. Time to appropriate therapy was measured from blood culture collection to the receipt of antibiotics with in vitro activity to the infecting organism. Cox proportional hazard models were used to measure the association between receipt of appropriate empiric therapy and in-hospital mortality, statistically adjusting for patient and pathogen characteristics.Among 814 admissions, 537 (66%) received appropriate empiric therapy. Those who received appropriate empiric therapy had a higher hazard of 30-day in-hospital mortality (Hazard Ratio (HR): 1.52; 95% confidence interval (CI): 0.99, 2.34). A longer time to appropriate therapy was protective against mortality (HR: 0.79; 95% CI: 0.60, 1.03) except among the healthiest quartile of patients (HR: 1.44; 95% CI: 0.66, 3.15).Appropriate empiric therapy was not associated with decreased mortality in patients with S. aureus bacteremia except in the least ill patients. Initial broad antibiotic selection may not be widely beneficial