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

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

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

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

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

Incorporating Electronic Medical Record Hard Stops to Reduce Inappropriate \u3cem\u3eClostridioides difficile\u3c/em\u3e Testing at an Academic Medical Center: A Quality Improvement Study

Background: Clostridioides difficile is the most common pathogen causing healthcare-associated infections. This study highlights the multi-disciplinary efforts to reduce C. difficile infections (CDI) at a large, tertiary care teaching facility. Methods: A quality improvement study was performed between March 2017 and April 2018, using six Plan-Do-Study-Act cycles that included transmission prevention, diagnostic stewardship, education, and antimicrobial stewardship. Process measures included hand hygiene, isolation precautions, low-level disinfection compliance, number of tests ordered, lab cancelation of tests, and compliance with the Electronic Medical Record (EMR) hard stop for patients with laxative use, and negative C.difficile test in the past 7 days. Results: A total of 2,046 C. difficile tests were ordered during the initiative. Of the 124 patients with a positive C. difficile LabID event, 50% were male with a median age of 65 years (range: 11–92 years). A 53% reduction in C. difficile LabID events (7.5 to 4 events per 10,000 patient-days, P \u3c 0.001), with a pronounced decrease between cycle 4 and 5 (5.4 to 2.9 events per 10,000 patient-days, P \u3c 0.001) was achieved. The largest decrease in C. difficile lab tests ordered was seen after implementation of the EMR hard-stop (cycle 5), with fewer than 0.5 LabID events per 1,000 patient-days for each subsequent month after EMR hard-stop implementation. Frequent reasons for physician phone calls to Infection prevention department was related to chronic use of lactulose in patients with cirrhosis (30%) and unexplained diarrhea (70%). Based on provider feedback, EMR changes were made to remove lactulose from the hard-stop and offer infectious disease consultation upfront. There was 99% compliance with electronic medical record hard stop. There was a nonsignificant increase in lab cancelations due to inappropriate stool specimens over time (1.9% to 3.1% from cycle 1 to 6, P = 0.28) A 55% reduction in hospital-onset CDI surveillance events (from 6.9 to 3.2 per 10,000 patient-days, P \u3c 0.001) was noted. Conclusion: A multi-disciplinary Quality Improvement initiative is a successful strategy in reducing CDI events, with the largest decrease seen with introduction of EMR hard stops

Incorporating Electronic Medical Record Hard Stops to Reduce Inappropriate \u3cem\u3eClostridioides difficile\u3c/em\u3e Testing at an Academic Medical Center: A Quality Improvement Study

Background: Clostridioides difficile is the most common pathogen causing healthcare-associated infections. This study highlights the multi-disciplinary efforts to reduce C. difficile infections (CDI) at a large, tertiary care teaching facility. Methods: A quality improvement study was performed between March 2017 and April 2018, using six Plan-Do-Study-Act cycles that included transmission prevention, diagnostic stewardship, education, and antimicrobial stewardship. Process measures included hand hygiene, isolation precautions, low-level disinfection compliance, number of tests ordered, lab cancelation of tests, and compliance with the Electronic Medical Record (EMR) hard stop for patients with laxative use, and negative C.difficile test in the past 7 days. Results: A total of 2,046 C. difficile tests were ordered during the initiative. Of the 124 patients with a positive C. difficile LabID event, 50% were male with a median age of 65 years (range: 11–92 years). A 53% reduction in C. difficile LabID events (7.5 to 4 events per 10,000 patient-days, P \u3c 0.001), with a pronounced decrease between cycle 4 and 5 (5.4 to 2.9 events per 10,000 patient-days, P \u3c 0.001) was achieved. The largest decrease in C. difficile lab tests ordered was seen after implementation of the EMR hard-stop (cycle 5), with fewer than 0.5 LabID events per 1,000 patient-days for each subsequent month after EMR hard-stop implementation. Frequent reasons for physician phone calls to Infection prevention department was related to chronic use of lactulose in patients with cirrhosis (30%) and unexplained diarrhea (70%). Based on provider feedback, EMR changes were made to remove lactulose from the hard-stop and offer infectious disease consultation upfront. There was 99% compliance with electronic medical record hard stop. There was a nonsignificant increase in lab cancelations due to inappropriate stool specimens over time (1.9% to 3.1% from cycle 1 to 6, P = 0.28) A 55% reduction in hospital-onset CDI surveillance events (from 6.9 to 3.2 per 10,000 patient-days, P \u3c 0.001) was noted. Conclusion: A multi-disciplinary Quality Improvement initiative is a successful strategy in reducing CDI events, with the largest decrease seen with introduction of EMR hard stops

The Epidemiology, Demographics, and Geographical Distribution of Human Non-Tuberculosis Mycobacteria (NTM) Disease in the Endemic Central Florida Region

Background: Of the \u3e100,000 people in the United States infected yearly with non-tuberculosis mycobacteria (NTM), Florida has the highest yearly incidence and prevalence of NTM disease. However, little has been documented on the epidemiology and distribution of NTM disease within Central Florida. Methods: A retrospective case review study was conducted from January, 2011 to December, 2017 at a large tertiary acute care medical center in Tampa, Florida to identify all NTM infection cases. Demographics (age, sex at birth, ethnicity), comorbidities, HIV testing status, residential zip code, NTM species, and specimen sources were collected. Results: Of the 507 isolates, Mycobacterium abscessus group was the most common (45.4%; n = 230), and contained M. abscessus spp. abscessus (34.5%; n = 175), M. abscessus spp. massilense (8.7%; n = 44), and M. abscessus spp. bolletii (1.18%; n = 6). Other rapid growers were M. fortuitum species (6.9%; n = 35) and M. chelonae (2.56%; n = 13). Of the slower growers, M. gordonae (19.9%; n = 101) and M. avium complex (8.28%; n = 42) were the most common. Of the M. avium complex, M. chimera was most common (4.9%; n = 25). Samples were mostly isolated from sputum (51.7%; n = 262), bronchial lavage (26%; n = 132), skin and soft tissue (11%; n = 58), and blood (7.1%; n = 36). Of the 361 unique patients, average age was 59.2 years (12 to 95 years), with 47.6% (n = 172) greater than 65 years of age, and mostly male 57.9% (n = 208). Caucasians represented 73.4% (n = 265) of our cohort, and African Americans and Hispanics represented 16.3% (n = 59) and 6.8% (n = 24), respectively. Most cases were in those residing outside the Tampa Bay metro area 81.2% (n = 293/361). Notable comorbidities included COPD (n = 83), cystic fibrosis (n = 41), lung transplant (n = 40), heart transplant (n = 12), pulmonary fibrosis (n = 12), and renal transplant (n = 7). A total of 145 individuals received HIV testing at the hospital facility, and of these 44 individuals were living with HIV. Conclusion: This study identified a diversity of NTM species across a wide geographical and demographic distribution in the endemic Central Florida region. M. abscessus group had the highest prevalence. This is valuable in understanding which populations are at risk for developing NTM infection in this area of Florida