Fosfomycin Utilization and Outcomes in a Large VA Medical Center Over a Decade

Background: Urinary tract infection (UTI) is one of the most common infectious diagnoses and in 2007 accounted for 10.5 million primary care visits in the US Advancing age and comorbidities, such as chronic kidney disease (CKD) and diabetes, affect antimicrobial prescribing habits. Sulfamethoxazole/trimethoprim (SMX-TMP), nitrofurantoin, and fosfomycin are first-line recommendations for uncomplicated cystitis. In an aging male population with potential allergies or contraindications to the above, fosfomycin is a potential option for treatment. Methods: A retrospective chart review of fosfomycin prescribing habits at a large VA academic medical center. Patients were selected based on fosfomycin prescription in both inpatient and outpatient settings from January 1, 2004 to December 5, 2017. Data reviewed included indication, organism(s), susceptibility, duration of treatment, CKD, and clinical success. Treatment success was defined as no representation with UTI symptoms for 30 days. Results:117 cases of UTI in which fosfomycin was used were identified with a median patient age of 70 years old and 90% male. Twenty-five were uncomplicated cystitis, 49 complicated cystitis, and 34 catheter associated infections. Treatment success was obtained in 92% of the uncomplicated cystitis cases, 76% in complicated cystitis cases, and 67% in catheter associated UTIs. In half of all the cases an ESBL bacterium was isolated and 79% were successfully treated with fosfomycin. The most common pathogen identified was E. coli 58/118 (49%), followed by Klebsiella 25/118 (21%). Conclusion: Fosfomycin is an antibiotic recommended for simple cystitis due to its safety profile, less collateral damage (gut flora disturbance), and low resistance as currently known. This review displays the largest ESBL cohort identified in the literature and uniquely used in a predominant male population. These findings suggest that ESBL producing bacteria can be treated successfully with fosfomycin in a male population as well as uncomplicated cystitis. However, caution should be used with catheterized patients as treatment was less effective regardless of isolated bacteria

Fosfomycin Utilization and Outcomes in a Large VA Medical Center Over a Decade

Background: Urinary tract infection (UTI) is one of the most common infectious diagnoses and in 2007 accounted for 10.5 million primary care visits in the US Advancing age and comorbidities, such as chronic kidney disease (CKD) and diabetes, affect antimicrobial prescribing habits. Sulfamethoxazole/trimethoprim (SMX-TMP), nitrofurantoin, and fosfomycin are first-line recommendations for uncomplicated cystitis. In an aging male population with potential allergies or contraindications to the above, fosfomycin is a potential option for treatment. Methods: A retrospective chart review of fosfomycin prescribing habits at a large VA academic medical center. Patients were selected based on fosfomycin prescription in both inpatient and outpatient settings from January 1, 2004 to December 5, 2017. Data reviewed included indication, organism(s), susceptibility, duration of treatment, CKD, and clinical success. Treatment success was defined as no representation with UTI symptoms for 30 days. Results:117 cases of UTI in which fosfomycin was used were identified with a median patient age of 70 years old and 90% male. Twenty-five were uncomplicated cystitis, 49 complicated cystitis, and 34 catheter associated infections. Treatment success was obtained in 92% of the uncomplicated cystitis cases, 76% in complicated cystitis cases, and 67% in catheter associated UTIs. In half of all the cases an ESBL bacterium was isolated and 79% were successfully treated with fosfomycin. The most common pathogen identified was E. coli 58/118 (49%), followed by Klebsiella 25/118 (21%). Conclusion: Fosfomycin is an antibiotic recommended for simple cystitis due to its safety profile, less collateral damage (gut flora disturbance), and low resistance as currently known. This review displays the largest ESBL cohort identified in the literature and uniquely used in a predominant male population. These findings suggest that ESBL producing bacteria can be treated successfully with fosfomycin in a male population as well as uncomplicated cystitis. However, caution should be used with catheterized patients as treatment was less effective regardless of isolated bacteria

Sticks and bones: Traumatic phaeohyphomycosis presenting as an epidural scalp abscess and cranial osteomyelitis

The pigmented molds can cause soft tissue and invasive disease (phaeohyphomycosis) in immunocompetent patients. We describe a 76-year-old male patient who developed a Cladophialophora bantiatum posterior scalp abscess and cranial osteomyelitis following an incidental scalp exposure with a tree branch. Management requires extensive surgical debridement followed by prolonged antifungal therapy. Keywords: Phaeohyphomycosis, Cranial, Osteomyelitis, Cladosporium, Cladophialophora bantiatu

Mycobacterium fortuitum ventriculoperitoneal shunt infection in an immunocompromised patient: A case report

We present a case of Mycobacterium fortuitum ventriculoperitoneal shunt infection in a 26-year-old immunocompromised woman. The patient was treated with revision and replacement of her peritoneal shunt and prolonged combination antimicrobial therapy. There are no established guidelines for the treatment of VP shunt infections due to M. fortuitum. We review the literature and provide treatment recommendations

Improving Infectious Disease Electronic Medical Records Documentation: A Quality Improvement Study in an Academic Teaching Hospital

Background: Improving efficiency of documentation and sign outs during transitions of care were identified as areas of interest by the University of South Florida Infectious Disease (ID) Division. Our aim is by May 2018, we will achieve \u3e50% improvement in our ID EMR note efficiency score for any adult patient at Tampa General Hospital. Note efficiency score involves listing all of the following key elements with 1 point awarded for each: active problem in the subjective section, updated hospital course under assessment, active problem prioritized first under assessment and non-relevant problems removed from assessment. Methods: Institute of Healthcare Improvement’s model with Plan-Do-Study-Act (PDSA) cycles was used for project implementation from March 2018 to May 2018 (Figure 1). Cycle 1: Conducting a needs assessment survey and education. Cycle 2: Changing the existing template and implementing a new standardized template that includes the key elements, along with removal of auto populated non relevant information. Audits of notes with a 4-point system scoring was done. A pre and post implementation physician survey was conducted. Results: ID fellow and faculty completed the baseline survey (N = 25). Less than half (46%) felt that they could interpret patient assessments with ease and even fewer respondents (36%) felt there was adequate weekend sign out. More than one-third (36%) reported writing majority of notes after 5 pm (Figure 1). Pilot project involved nine ID faculty and fellows. We had 95% compliance with use of the standardized EMR template. Notes were evaluated at baseline (n = 190), cycle 1 (n = 85), and cycle 2 (n = 56). An increase in average note efficiency score from baseline, cycle 1 and cycle 2 occurred as follows (Mean ± SD): 2.0 ± 0.84 vs. 2.8 ± 0.95 vs. 3.6 ± 0.5 (Figure 2). Compared with baseline, cycle 2 achieved 42% improvement in the ease of interpretation of patient assessments and 41% improvement in adequate sign out. No increase in note writing after 5pm (36% vs. 30% baseline and cycle 2, respectively) reported. Conclusion: Targeted education and changing the EMR note template can achieve improved efficiency of ID note. These efforts to improve documentation enhance physician’s ease of interpretation of patient assessments and sign out during transition of care

Improving Infectious Disease Electronic Medical Records Documentation: A Quality Improvement Study in an Academic Teaching Hospital

Background: Improving efficiency of documentation and sign outs during transitions of care were identified as areas of interest by the University of South Florida Infectious Disease (ID) Division. Our aim is by May 2018, we will achieve \u3e50% improvement in our ID EMR note efficiency score for any adult patient at Tampa General Hospital. Note efficiency score involves listing all of the following key elements with 1 point awarded for each: active problem in the subjective section, updated hospital course under assessment, active problem prioritized first under assessment and non-relevant problems removed from assessment. Methods: Institute of Healthcare Improvement’s model with Plan-Do-Study-Act (PDSA) cycles was used for project implementation from March 2018 to May 2018 (Figure 1). Cycle 1: Conducting a needs assessment survey and education. Cycle 2: Changing the existing template and implementing a new standardized template that includes the key elements, along with removal of auto populated non relevant information. Audits of notes with a 4-point system scoring was done. A pre and post implementation physician survey was conducted. Results: ID fellow and faculty completed the baseline survey (N = 25). Less than half (46%) felt that they could interpret patient assessments with ease and even fewer respondents (36%) felt there was adequate weekend sign out. More than one-third (36%) reported writing majority of notes after 5 pm (Figure 1). Pilot project involved nine ID faculty and fellows. We had 95% compliance with use of the standardized EMR template. Notes were evaluated at baseline (n = 190), cycle 1 (n = 85), and cycle 2 (n = 56). An increase in average note efficiency score from baseline, cycle 1 and cycle 2 occurred as follows (Mean ± SD): 2.0 ± 0.84 vs. 2.8 ± 0.95 vs. 3.6 ± 0.5 (Figure 2). Compared with baseline, cycle 2 achieved 42% improvement in the ease of interpretation of patient assessments and 41% improvement in adequate sign out. No increase in note writing after 5pm (36% vs. 30% baseline and cycle 2, respectively) reported. Conclusion: Targeted education and changing the EMR note template can achieve improved efficiency of ID note. These efforts to improve documentation enhance physician’s ease of interpretation of patient assessments and sign out during transition of care