Association between duration of antipseudomonal beta-lactam therapy and Clostridioides difficile infections in monomicrobial Enterobacterales bloodstream infections at an academic medical center

Missed Opportunities for Early De-Escalation of Antipseudomonal Beta-Lactam Antimicrobial Therapy in Enterobacterales Bloodstream Infection

Background: Antipseudomonal β-lactams (APBL) are commonly used for empirical therapy of Gram-negative bloodstream infections (BSI). This retrospective cohort study examines risk factors for prolonged APBL use (≥48 h) in patients with Enterobacterales BSI and compares 28-day mortality between early de-escalation of APBL and prolonged APBL therapy. Methods: Adult patients admitted to two community hospitals in South Carolina with Enterobacterales BSI from January 2010 to June 2015 were included in this study. Data were extracted manually from medical records. Multivariate logistic regression and Cox proportional hazards analyses were used to examine predictors of prolonged APBL therapy and mortality, respectively. Results: Among 993 patients with Enterobacterales BSI, 491 (49%) underwent early de-escalation of APBL and 502 (51%) received prolonged APBL therapy. Cancer, immune compromised status, residence at a skilled nursing facility, a high Pitt bacteremia score, non-urinary source of infection, and BSI due to AmpC-producing Enterobacterales were independently associated with prolonged use of APBL. Antimicrobial stewardship interventions were inversely associated with prolonged APBL use. Early de-escalation of APBL was not associated with increased mortality. Conclusions: This study exemplifies the safety and effectiveness of early de-escalation of APBL in Enterobacterales BSI. Antimicrobial stewardship strategies should be implemented to encourage the practice of early de-escalation of antimicrobial therapy, including in high-risk populations.

Incidence and variability in receipt of phenotype-desirable antimicrobial therapy for Enterobacterales bloodstream infections among hospitalized United States patients

Background

Using a large, geographically diverse, hospital-based database in the United States (Premier PINC AI Healthcare Database), we aimed to describe the proportion and characteristics of patients receiving phenotype-desirable antimicrobial therapy (PDAT) among those hospitalized with Enterobacterales bloodstream infections.

Methods

Adult patients with an admission between January 1, 2017 and June 30, 2022 with ≥1 blood culture positive for Escherichia coli, Klebsiella oxytoca, Klebsiella pneumoniae, or Proteus mirabilis and receiving an empiric antibiotic therapy on blood culture collection (BCC) Days 0 or 1 were included. Receiving PDAT (defined as receipt of any antimicrobial categorized as "desirable" for the respective phenotype) on BCC Days 0-2 was defined as receiving early PDAT.

Results

Among 35,880 eligible patients, the proportion of patients receiving PDAT increased (from 6.8% to 22.8%) from BCC Day 0-4. Patients who received PDAT (8,193, 22.8%) were more likely to visit large (500 + beds, 36% vs 31%), teaching (45% vs 39%), and urban (85% vs 82%) hospitals in the Northeast (22% vs 13%) compared to patients not receiving PDAT (all P <. 01). Among patients receiving PDAT, 61.4% (n = 5,033) received it early; they had a lower mean comorbidity score (3.2 vs 3.6), were less likely to have severe or extreme severity of illness (71% vs 79%), and were less likely to have a pathogen susceptible to narrow-spectrum β-lactams (31% vs 71%) compared to patients in the delayed PDAT group (all P < .01).

Conclusions

The proportion of patients receiving desirable therapy increased between BCC Day 0 and 4. Receipts of PDAT and early PDAT were associated with hospital, clinical, and pathogen characteristics.

The impact of implementation of rapid blood culture identification panels on antimicrobial optimization: a retrospective cohort study

Objective

Determine the impact of limited implementation of a rapid blood culture identification (BCID) panel.

Design

Retrospective cohort study.

Methods

From February to April 2022, positive blood cultures identified via e-Plex BCID (Roche, Carlsbad, CA) were compared to those identified using standard microbial identification techniques. The primary outcomes assessed were time to optimal therapy, time to de-escalation of anti-MRSA (methicillin-resistant Staphylococcus aureus) agents, and time to de-escalation of anti-pseudomonal agents. Additional analysis investigated the impact of the availability of antimicrobial stewardship program support. This study was conducted at Grady Health System, a large metropolitan safety-net hospital in the southeastern United States.

Results

A total of 253 blood cultures were included in this study (153 BCID and 100 standard). Blood culture identification use was associated with a reduction in median time to optimal antimicrobial therapy (43.4 vs 72.1 h, P < .001) and median time to de-escalation of anti-MRSA agents (27.7 vs 46.7 h, P = .006), and a trend towards reduction of median time to de-escalation of anti-pseudomonal agents (38.8 vs 54.8 h, P = .07). These reductions persisted when controlling for patient age, sex, intensive care unit status, Charlson Comorbidity Index, and antimicrobial stewardship program availability.

Conclusions

Despite restricted use and lack of 24/7 antimicrobial stewardship program availability, BCID panel utilization was associated with earlier initiation of optimal therapy and pathogen identification with subsequent de-escalation of broad-spectrum antimicrobials, as compared to standard antimicrobial techniques. This suggests the potential for benefit from adopting novel diagnostic technologies outside of idealized fully-resourced settings.

Association Between Common Empiric Antibiotic Regimens and Clostridioides Difficile Infection in Pediatric Appendicitis

BACKGROUND

Clostridioides Difficile Infection (CDI) is a serious antibiotic related complication that has been reported among children undergoing treatment of appendicitis. CDI likelihood amongst different empiric antibiotic regimens for appendicitis remains unclear but likely has important implications for antibiotic stewardship.

METHODS

A retrospective cohort study of the Pediatric Health Information System was used to examine patients ages 1 through 18 who received operative management of acute appendicitis. Common empiric antibiotic regimens 1) Ceftriaxone & Metronidazole (CM) 2) Piperacillin & Tazobactam (PT) and 3) Cefoxitin were compared. Study outcomes were CDI within 28 days post-appendectomy and 30-day post-appendectomy percutaneous drainage procedures. Subset analyses were repeated to only include hospitals that standardized empiric antibiotic choice.

RESULTS

Of 105,911 patients, 220 (0.21 %) developed CDI. CDI was more common in patients that received CM (CM 0.29 % vs PT 0.15 % vs Cefoxitin 0.18 %; P < 0.01). On adjusted analysis, PT was associated with a lower likelihood of CDI (OR, 0.48; 95%CI, 0.31-0.74) compared to CM which was consistent in hospitals with standardized antibiotic choice. Exposure to more unique antibiotic regimens (OR, 1.70; 95 % CI, 1.50-1.93) and higher total antibiotic days (OR, 1.17; 95 % CI 1.13-1.21) were associated with an increased likelihood of CDI. There was no significant difference in the likelihood of post-appendectomy percutaneous drainage between antibiotic regimens.

CONCLUSIONS

CDI is rare following appendectomy for pediatric appendicitis. While PT was associated with statistically lower rates of CDI compared to CM, antibiotic stewardship efforts to avoid mixed regimens and decrease overall antibiotic exposure warrant exploration.

LEVEL OF EVIDENCE

Level III.

Predictors of hospital-onset Clostridioides difficile infection in children with antibiotic-associated diarrhea

BACKGROUND

This study aimed to determine the predictors of hospital-onset Clostridioides difficile infection (CDI) in pediatric patients with antibiotic-associated diarrhea (AAD) and to develop a predictive scoring system to identify at-risk patients.

METHODS

This retrospective case-control study included patients aged ≥2-18 years with AAD who underwent C. difficile polymerase chain reaction testing >3 days after hospital admission. Patients with hospital-onset CDI were selected as cases and matched with the control patients without CDI. Univariate and multivariate logistic regressions were used to determine predictors of CDI and to construct a prediction score for the outcomes of interest.

RESULTS

Sixty-five patients with hospital-onset CDI and 130 controls were enrolled. Independent predictors for CDI identified and combined into the prediction score included abdominal pain (adjusted odds ratio [95% confidence interval]: 7.940 [3.254-19.374]), hospitalization for ≥14 days before the onset of diarrhea (3.441 [1.034-11.454]), antibiotic use for ≥10 days before the onset of diarrhea (6.775 [1.882-24.388]), receipt of meropenem (4.001 [1.098-14.577]) and clindamycin (14.842 [4.496-49.000]). The area under the receiver operating characteristic curve for this score was 0.883.

CONCLUSIONS

The presented scoring system can be easily applied by clinicians at the bedside to decide which patients with AAD are likely to have CDI.