Salvage of Hemodialysis Catheter in Staphylococcal Bacteremia: Case Series, Revisiting the Literature, and the Role of the Pharmacist

Catheter-related blood stream infections comprise a major concern in hemodialysis patients, leading to increased mortality, morbidity, and cost of treatment. Prompt appropriate systemic antibiotics treatment, which includes administration of appropriate systemic antibiotics and, frequently, catheter removal and replacement, is warranted. However, in hemodialysis patients, repeated catheter insertions may cause central vein stenosis and thrombosis which limits the future availability of hemodialysis access. Lock solutions containing antibiotics and anticoagulants, instilled directly into the catheter lumen after each dialysis, have been successfully utilized for catheter salvage but higher rates of recurrence and complications were observed in infections resulting from staphylococcal species. We report several cases of catheter salvage using antibiotic lock solution in staphylococcal bacteremia with the purpose of stimulating the interest in randomized clinical trials. Evaluating the risk and benefits of catheter salvage in this patient subset in light of optimized systemic antibiotic dosing, improved lock solution use, and multidisciplinary involvement, balanced with the critical need to prevent unnecessary vascular trauma, is of great importance

Treatment of recurrent urinary tract infections in anuric hemodialysis patient, do we really need antimicrobial urinary concentration?

Providing care for patients with chronic kidney disease requires considerations that are unique to this population. Several references recommend the treating urinary tract infections with antibiotics that achieve considerable concentrations in urine however this is not applicable in anuric patients undergoing hemodialysis who are unable to excrete antibiotics significantly in urine. We report successful treatment of several episodes of urinary tract infections in hemodialysis patient highlighting the questionable need for antimicrobial urine concentration

Meningitis as the initial manifestation of systemic lupus erythematosus

Systemic Lupus Erythematosus (SLE) is an idiopathic chronic autoimmune disease that can affect multiple organs including the Central Nervous System (CNS). CNS involvement is seen in many SLE patients; however, usually it is preceded by/or in conjunction with other organ-system involvement. The spectrum of CNS involvement is wide and includes numerous neuro-psychiatric syndromes but rarely meningitis. Even when meningitis occurs it is almost never the presenting manifestation of SLE. Our case had chronic aseptic meningitis as the initial and seemingly sole manifestation of SLE, which was erroneously, treated as tuberculous (TB) meningitis

Predicting Maintenance Doses of Vancomycin for Hospitalized Patients Undergoing Hemodialysis

ABSTRACTBackground: Methicillin-resistant Staphylococcus aureus is a leading cause of death in patients undergoing hemodialysis. However, controversy exists about the optimal dose of vancomycin that will yield the recommended pre-hemodialysis serum concentration of 15–20 mg/L.Objective: To develop a data-driven model to optimize the accuracy of maintenance dosing of vancomycin for patients undergoing hemodialysis.Methods: A prospective observational cohort study was performed with 164 observations obtained from a convenience sample of 63 patients undergoing hemodialysis. All vancomycin doses were given on the floor after completion of a hemodialysis session. Multivariate linear generalized estimating equation analysis was used to examine independent predictors of pre-hemodialysis serum vancomycin concentration.Results: Pre-hemodialysis serum vancomycin concentration was independently associated with maintenance dose (B = 0.658, p < 0.001), baseline pre-hemodialysis serum concentration of the drug (B = 0.492, p < 0.001), and interdialytic interval (B = –2.133, p < 0.001). According to the best of 4 models that were developed, the maintenance dose of vancomycin required to achieve a pre-hemodialysis serum concentration of 15–20 mg/L, if the baseline serum concentration of the drug was also 15–20 mg/L, was 5.9 mg/kg with interdialytic interval of 48 h and 7.1 mg/kg with interdialytic interval of 72 h. However, if the baseline pre-hemodialysis serum concentration was 10–14.99 mg/L, the required dose increased to 9.2 mg/kg with an interdialytic interval of 48 h and 10.0 mg/kg with an interdialytic interval of 72 h.Conclusions: The maintenance dose of vancomycin varied according to baseline pre-hemodialysis serum concentration of the drug and interdialytic interval. The current practice of targeting a pre-hemodialysis concentration of 15–20 mg/L may be difficult to achieve for the majority of patients undergoing hemodialysis.RÉSUMÉContexte : Les infections à Staphylococcus aureus résistant à la méthicilline comptent parmi les principales causes de mortalité chez les patients traités par hémodialyse. Or, les avis sont partagés quant à la dose optimale de vancomycine qui permet d’atteindre la concentration sérique recommandée de 15–20 mg/L préalablement à l’hémodialyse.Objectif : Mettre au point un modèle guidé par des données afin d’optimiser l’exactitude de la dose d’entretien de vancomycine chez les patients qui subissent une hémodialyse.Méthodes : Une étude de cohorte prospective observationnelle a été menée à partir de 164 observations obtenues d’un échantillon de commodité de 63 patients traités par hémodialyse. Toutes les doses de vancomycine ont été données à l’unité de soins courants après la fin d’une séance d’hémodialyse. Une analyse de régression linéaire multiple par équation d’estimation généralisée a été effectuée pour cerner les variables indépendantes qui permettent de prévoir la concentration sérique de vancomycine préalablement à l’hémodialyse.Résultats : La concentration sérique de vancomycine avant hémodialyse a été associée de façon indépendante à l’intervalle entre deux dialyses (B = –2,133, p < 0,001), à la dose d’entretien (B = 0,658, p < 0,001) et à la concentration sérique initiale du médicament préalablement à l’hémodialyse (B = 0,492, p < 0,001). Selon les quatre meilleurs modèles élaborés, la dose d’entretien de vancomycine nécessaire pour atteindre une concentration sérique de 15–20 mg/L avant hémodialyse, si la valeur initiale était aussi de 15–20 mg/L, était de 5,9 mg/kg pour un intervalle de 48 h entre deux dialyses et de 7,1 mg/kg pour un intervalle de 72 h entre deux dialyses. Or, si la concentration sérique initiale préalablement à l’hémodialyse se situait entre 10 et 14,99 mg/L, la dose necessaire augmentait à 9,2 mg/kg pour un intervalle de 48 h entre deux dialyses et à 10,0 mg/kg pour un intervalle de 72 h écoulé entre deux dialyses.Conclusions : La dose d’entretien de vancomycine variait en fonction de la concentration sérique initiale du médicament préalablement à l’hémodialyse et en fonction de l’intervalle entre deux dialyses. La pratique actuelle voulant qu’on vise une concentration préalable à l’hémodialyse de 15–20 mg/L peut être difficile à respecter chez la majorité des patients subissant une hémodialyse

Correction: Simultaneous administration of imipenem/cilastatin/relebactam with selected intravenous antimicrobials, a stewardship approach.

[This corrects the article DOI: 10.1371/journal.pone.0233335.]

Simultaneous administration of imipenem/cilastatin/relebactam with selected intravenous antimicrobials, a stewardship approach.

Imipenem/cilastatin/relebactam is a β-lactam/β-lactamase inhibitor that has been recently FDA approved for complicated intra-abdominal and urinary tract infections under the brand name Recarbrio®. It has activity against imipenem non-susceptible Pseudomonas species as well as KPC-producing Enterobacteriaceae. Optimization of PK/PD of antimicrobials particularly in critically-ill patients is essential, but unfortunately, is hindered by separate administration that requires significant resources. The objective of the study is to investigate the compatibility of Y-site administration of imipenem/cilastatin/relebactam with a wide range of antimicrobials. After admixture, physical characteristics, pH changes and turbidity were measured for each 2-drug combination at a time. With the exception of amphotericin B deoxycholate, and posaconazole, imipenem/cilastatin/relebactam was compatible with a variety of antimicrobial agents. The compatibility profile described, will facilitate incorporation into hospital protocols, contribute to therapy optimization and guide clinicians to avoid successive administration, consequently resulting in reduction of total infusion time, optimization of PK/PD, economizing nursing time and cost containment

Risk Factors for Recurrence of Clostridioides difficile in Hospitalized Patients

Background: Diarrhea and pseudomembranous colitis associated with Clostridioides difficile - a spore-forming anaerobic Gram-positive bacillus - is a major infection in hospitalized patients with a profound impact on clinical and economic outcomes. Recurrence (rCDI) is common and predisposes to further episodes with poor outcomes. Method: We aimed to identify a wide range of risk factors for recurrence to guide stewardship initiatives. After ethical approval, we commenced collecting demographic and clinical data of patients older than 18 years with clinically and microbiologically confirmed C. difficile infection. Data were statistically analyzed using R software. Results: Of 204 patients included in the analysis, 36 (18%) suffered 90-day recurrence, rCDI was higher among females (23%) compared to males (13%), overall age median (IQR) was 66 (51-77), and for rCDI cases 81 (69-86) years. Among 26 variables analyzed to evaluate their association with rCDI, prior clindamycin exposure, concurrent use of aztreonam, patients \u3e76 years, total hospital length of stay, and LOS before diagnosis ≤7 days, WBC ≤ 9.85 × 103 at discharge were more likely to experience rCDI. Conclusion: As identified in this analysis, patients with risk factors for rCDI could be candidates for close monitoring, a high index of suspicion, and risk mitigation interventions to avoid rCDI and improve clinical outcomes

The prevalence of cardiorenal anemia syndrome among patients with heart failure and its association with all-cause hospitalizations: a retrospective single-center study from the Middle East

Background and aimLittle is known about the burden of cardiorenal syndrome (CRS) and cardiorenal anemia syndrome (CRAS) in the Middle East Region. Furthermore, whether the occurrence rates of CRAS differ across heart failure (HF) phenotypes is not widely investigated. We aimed to examine the prevalence of CRS and CRAS in patients with HF, compare characteristics of patients with CRAS-HFrEF vs. CRAS-HFpEF, and investigate anemia association with 1-year all-cause hospitalizations.MethodsHF patients who visited a multidisciplinary HF clinic at a single center between 10-2015 and 06-2022 (n = 968) were retrospectively included. Differences in rates of CRAS prevalence, and patients’ characteristics of those with CRAS-HFrEF vs. CRAS-HFpEF were determined using appropriate testing methods. Generalized estimating equation (GEE) models were used to determine if anemia was associated with higher rates of hospitalization.ResultsCRS was prevalent in 34.4% of subjects, while 25.3% had CRAS. CRAS prevalence rates among patients with HFpEF vs. HFrEF were comparable (27.2% vs. 24.2%, p = 0.3). Compared to patients with HFrEF-CRAS, those with HFpEF-CRAS were more likely females (p < 0.001), had a higher burden of hypertension (p = 0.01), and lower hemoglobin (p = 0.02). In an adjusted GEE model, anemia was associated with an average increase of 1.8 admissions in CRS patients (p = 0.015).ConclusionIn patients with HF, 1 in 3 patients presented with CRS, and 1 in 4 patients had CRAS. The prevalence of CRAS was comparable among those HFpEF and HFrEF. Anemia was associated with an increased rate of 1-year all-cause hospitalization in CRS patients