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Hollingshead CM, Khazan AE, Franco JH, Ciricillo JA, Haddad MN, Berry JT, Kammeyer JA. A Needs Assessment for Infectious Diseases Consultation in Community Hospitals. Infect Dis Ther 2023:10.1007/s40121-023-00810-4. [PMID: 37243912 DOI: 10.1007/s40121-023-00810-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Accepted: 04/14/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION Infectious diseases (ID) consultations have been demonstrated to improve patient outcomes in the treatment of severe infections. However, ID consultation is often unavailable to patients that live in rural communities. Little is known regarding the treatment of infections in rural hospitals with no coverage from an ID specialist. We characterized the outcomes of patients cared for in hospitals without coverage from an ID physician. METHODS Patients aged 18 years or older admitted to eight community hospitals without access to ID consultation during a 6.5-month period were assessed. All patients had received at least three days of continuous antimicrobial therapy. The primary outcome was the need for transfer to a tertiary facility for ID services. The secondary outcome was the characterization of antimicrobials received. Antimicrobial courses were evaluated independently by two board-certified ID physicians. RESULTS 3706 encounters were evaluated. Transfers for ID consultation occurred in 0.01% of patients. The ID physician would have made modifications in 68.5% of patients. Areas for improvement included treatment of chronic obstructive pulmonary disease exacerbations, broad-spectrum treatment of skin and soft tissue infection, long courses of azithromycin, and management of Staphylococcus aureus bacteremia, including choice and length of therapy, as well as obtaining echocardiography. Patients evaluated received 22,807 days of antimicrobial therapy. CONCLUSIONS Patients hospitalized in community hospitals are rarely transferred for ID consultation. Our work demonstrates a need for ID consultation in community hospitals, identifying opportunities to enhance patient care by modifying antimicrobial regimens to improve antimicrobial stewardship and avoid inappropriate antimicrobials. Efforts to expand the ID workforce to include coverage at rural hospitals will likely improve antibiotic utilization.
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Affiliation(s)
- Caitlyn M Hollingshead
- Division of Infectious Diseases, University of Toledo College of Medicine and Life Sciences, 3000 Arlington Avenue, Mail Stop: 1186, Toledo, OH, 43614, USA.
| | - Ana E Khazan
- Department of Internal Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Justin H Franco
- Department of Medical Microbiology and Immunology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Jacob A Ciricillo
- Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Michael N Haddad
- Department of Internal Medicine, St. Vincent Charity Medical Center, Cleveland, OH, USA
| | - Julia T Berry
- Department of Obstetrics and Gynecology, William Beaumont Hospital, Royal Oak, MI, USA
| | - Joel A Kammeyer
- Division of Infectious Diseases, University of Toledo College of Medicine and Life Sciences, 3000 Arlington Avenue, Mail Stop: 1186, Toledo, OH, 43614, USA.
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Whittington KJ, Ma Y, Butler AM, Hogan PG, Ahmed F, Flowers J, Milburn G, Morelli JJ, Newland JG, Fritz SA. The impact of infectious diseases consultation for children with Staphylococcus aureus bacteremia. Pediatr Res 2022; 92:1598-1605. [PMID: 35982140 PMCID: PMC9789160 DOI: 10.1038/s41390-022-02251-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 07/14/2022] [Accepted: 07/27/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Despite clear benefit of improved outcomes in adults, the impact of infectious diseases (ID) consultation for Staphylococcus aureus bacteremia in children remains understudied. METHODS To assess the impact of pediatric ID consultation on management and outcomes, we conducted a cohort study of children with S. aureus bacteremia at St. Louis Children's Hospital from 2011 to 2018. We assessed adherence to six established quality-of-care indicators (QCIs). We applied propensity score methodology to examine the impact of ID consultation on risk of treatment failure, a composite of all-cause mortality or hospital readmission within 90 days. RESULTS Of 306 patients with S. aureus bacteremia, 193 (63%) received ID consultation. ID consultation was associated with increased adherence to all QCIs, including proof-of-cure blood cultures, indicated laboratory studies, echocardiography, source control, targeted antibiotic therapy, and antibiotic duration. Obtaining proof-of-cure blood cultures and all indicated laboratory studies were associated with improved outcomes. In propensity score-weighted analyses, risk of treatment failure was similar among patients who did and did not receive ID consultation. However, the number of events was small and risk estimates were imprecise. CONCLUSIONS For children with S. aureus bacteremia, ID consultation improved adherence to QCIs, some of which were associated with improved clinical outcomes. IMPACT In children with Staphylococcus aureus bacteremia, consultation by an infectious diseases (ID) physician improved adherence to established quality-of-care indicators (QCIs). The current literature regarding ID consultation in pediatric S. aureus bacteremia is sparse. Three prior international studies demonstrated improved quality of care with ID consultation, though results were disparate regarding clinical outcomes. This article impacts the current literature by strengthening the evidence that ID consultation in children improves adherence to QCIs, and demonstrates that adherence to QCIs improves clinical outcomes.
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Affiliation(s)
- Kyle J. Whittington
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Yinjiao Ma
- Department of Medicine Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Anne M. Butler
- Department of Medicine Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Patrick G. Hogan
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Faria Ahmed
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - JessieAnn Flowers
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Grace Milburn
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - John J. Morelli
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Jason G. Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA
| | - Stephanie A. Fritz
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, 63110, USA,Corresponding author: Stephanie A. Fritz, MD, MSCI, 660 S. Euclid Avenue, MSC 8116-43-10, St. Louis, MO 63110-9872, , Phone: (314) 454-6050
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Kufel WD, Mastro KA, Steele JM, Wang D, Riddell SW, Paolino KM, Thomas SJ. Impact of a pharmacist-facilitated, evidence-based bundle initiative on Staphylococcus aureus bacteremia management. Diagn Microbiol Infect Dis 2021; 101:115535. [PMID: 34634714 DOI: 10.1016/j.diagmicrobio.2021.115535] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/22/2021] [Accepted: 08/29/2021] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate a pharmacist-facilitated evidence-based bundle (EBB) initiative with infectious disease consultation (IDC) for Staphylococcus aureus bacteremia (SAB). METHODS This was a before-and-after quasi-experimental study of adult patients with SAB before and after the pharmacist-facilitated EBB initiative, which included IDC, timely definitive antibiotics, source control, echocardiography, and repeat blood cultures. RESULTS Ninety and 111 patients were included in pre- and post-intervention cohorts, respectively. We observed significant increases in adherence to all 5 (4.4% vs 68.5%, P < 0.001) and 4 (10.0% vs 76.6%, P < 0.001) EBB elements. Time to definitive antibiotics (48 vs 16 hours, P < 0.001), time to IDC (43.5 vs 32 hours, P < 0.001), SAB duration (95 vs 66 hours, P = 0.009), persistent SAB (18.9% vs 9.0%, P = 0.041), and length of stay (14 vs 13 days, P = 0.027) also improved. No statistically significant differences for SAB-related readmission or all-cause mortality were observed. CONCLUSIONS Our pharmacist-facilitated SAB initiative was associated with improved EBB adherence and clinical outcomes.
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Affiliation(s)
- Wesley D Kufel
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA; State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA.
| | - Keri A Mastro
- Binghamton University School of Pharmacy and Pharmaceutical Sciences, Binghamton, NY, USA; State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Jeffrey M Steele
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Dongliang Wang
- State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Scott W Riddell
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Kristopher M Paolino
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
| | - Stephen J Thomas
- State University of New York Upstate Medical University, Syracuse, NY, USA; State University of New York Upstate University Hospital, Syracuse, NY, USA
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McHale T, Medder J, Geske J, Rupp ME, Van Schooneveld TC. The Effect of Insurance on Appropriate Hospital Discharge Antibiotics for Patients With Staphylococcus aureus Bacteremia. Open Forum Infect Dis 2020; 8:ofaa568. [PMID: 33511223 PMCID: PMC7817079 DOI: 10.1093/ofid/ofaa568] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 11/16/2020] [Indexed: 11/13/2022] Open
Abstract
Background Inappropriate antimicrobial therapy of Staphylococcus aureus bacteremia (SAB) is associated with worsened outcomes. The impact of insurance coverage on appropriate selection of antibiotics at discharge is poorly understood. Methods We used a retrospective cohort design to evaluate whether patients with SAB at a large academic medical center over 2 years were more likely to receive inappropriate discharge antibiotics, depending on their category of insurance. Insurance was classified as Medicare, Medicaid, commercial, and none. Logistic regression was used to determine the odds of being prescribed inappropriate discharge therapy. Results A total of 273 SAB patients met inclusion criteria, with 14.3% receiving inappropriate discharge therapy. In the unadjusted model, there was 2-fold increased odds of being prescribed inappropriate therapy for Medicare, Medicaid, and no insurance, compared with commercial insurance, respectively (odds ratio [OR], 2.08; 95% CI, 1.39–3.13). After controlling for discharge with nursing assistance and infectious diseases (ID) consult, there were 1.6-fold increased odds (OR, 1.57; 95% CI, 0.998–2.53; P = .064) of being prescribed inappropriate therapy for Medicare, Medicaid, and no insurance, compared with commercial insurance, respectively. We found that being discharged home without nursing assistance resulted in 4-fold increased odds of being prescribed inappropriate therapy (OR, 4.16; 95% CI, 1.77–9.77; P < .01), and failing to consult an ID team resulted in 59-fold increased odds of being prescribed inappropriate therapy (OR, 59.2; 95% CI, 11.4–306.9; P < .001). Conclusions We found strong evidence that noncommercial insurance, discharging without nursing assistance, and failure to consult ID are risk factors for being prescribed inappropriate antimicrobial therapy for SAB upon hospital discharge.
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Affiliation(s)
- Thomas McHale
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jim Medder
- Department of Family Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jenenne Geske
- Department of Family Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mark E Rupp
- Division of Infectious Disease, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Trevor C Van Schooneveld
- Division of Infectious Disease, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Marks M, Morris-Jones S, Logan S, Pollara G. Routine Outpatient Parenteral Antimicrobial Therapy Clinic Review Minimizes Inpatient Readmission. Clin Infect Dis 2020; 71:2771-2773. [PMID: 32031214 DOI: 10.1093/cid/ciaa132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Michael Marks
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals, London, United Kingdom
- Clinical Research Department, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Stephen Morris-Jones
- Department of Clinical Microbiology, University College London Hospitals, London, United Kingdom
| | - Sarah Logan
- Hospital for Tropical Diseases, Division of Infection, University College London Hospitals, London, United Kingdom
| | - Gabriele Pollara
- Department of Clinical Microbiology, University College London Hospitals, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
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Reduction of 30-day death rates from Staphylococcus aureus bacteremia by mandatory infectious diseases consultation: Comparative study interventions with and without an infectious disease specialist. Int J Infect Dis 2020; 103:308-315. [PMID: 33278619 DOI: 10.1016/j.ijid.2020.11.199] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 11/12/2020] [Accepted: 11/26/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Most Japanese hospitals need to keep to higher Staphylococcus aureus bacteremia (SAB) quality-of-care indicators (QCIs) and create strategies that can maximize the effect of these QCIs with only a small number of infectious disease specialists. This study aimed to evaluate the clinical outcomes of patients with SAB before and after the enhancement of the mandatory infectious disease consultations (IDCs). METHODS This retrospective study was conducted at a tertiary care hospital in Japan. The primary outcome was the 30-day mortality between each period. A generalized structural equation model was employed to examine the effect of the mandatory IDC enhancement on 30-day mortality among patients with SAB. RESULTS A total of 114 patients with SAB were analyzed. The 30-day all-cause mortality differed significantly between the two periods (17.3% vs. 4.8%, P = 0.02). Age, three-QCI point ≥ 1, and Pitt bacteremia score ≥ 3 were the significant risk factors for 30-day mortality. The intervention was also significantly associated with improved adherence to QCIs. CONCLUSION Mandatory IDCs for SAB improved 30-day mortality and adherence to QCIs after the intervention. In Japan, improving the quality of management in patients with SAB should be an important target.
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Oh Y, Roh J, Lee J, Chung HS, Lee K, Lee MK. Sequential Organ Failure Assessment score as a predictor of mortality in ventilated patients with multidrug-resistant bacteremia. Acute Crit Care 2020; 35:169-178. [PMID: 32907310 PMCID: PMC7483015 DOI: 10.4266/acc.2020.00143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 06/25/2020] [Indexed: 12/21/2022] Open
Abstract
Background The occurrence of multidrug-resistant (MDR) bacteremia in ventilated patients may be associated with a high mortality rate. We evaluated whether Sequential Organ Failure Assessment (SOFA) score on the day of bacteremia could predict 90-day mortality in these patients. Methods Data were obtained retrospectively from 202 patients (male, 60.4%; median age, 64 years) hospitalized at a single university-affiliated tertiary care hospital. All adult patients who had were ventilated and had one of the following six MDR bacteremias between March 2011 and February 2018 were enrolled: methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing Gram-negative bacteria (Escherichia coli and Klebsiella pneumonia), carbapenem-resistant Gram-negative rods (Acinetobacter baumannii and Pseudomonas aeruginosa), or vancomycin-resistant Enterococcus faecium. Results The overall 90-day mortality rate after the day of bacteremia was 59.9%. The areas under the receiver operating characteristic curves for the SOFA and Acute Physiology and Chronic Health Evaluation (APACHE) II scores were 0.732 (95% confidence interval [CI], 0.666 to 0.792; P<0.001) and 0.662 (95% CI, 0.593 to 0.727; P<0.001), respectively, with no difference between the two (P=0.059). Also, the cutoff value of the SOFA score was 9 (based on Youden’s index). Multivariate Cox regression analysis showed that this cut-off value was significantly associated with higher mortality rate (hazard ratio, 2.886; 95% CI, 1.946 to 4.221; P<0.001). Conclusions SOFA score measured on the day of bacteremia may be a useful prognostic indicator of 90-day mortality in ventilated patients with MDR bacteremia.
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Affiliation(s)
- Yeseul Oh
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jiyeon Roh
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Jaemin Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Hyun Sung Chung
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Kwangha Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Min Ki Lee
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
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Draenert R, Jung N. [Choosing Wisely in Infectious Diseases - important recommendations for daily life in medicine]. MMW Fortschr Med 2020; 162:53-56. [PMID: 32248469 DOI: 10.1007/s15006-020-0342-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Rika Draenert
- Leitung Antibiotic Stewardship-Team, Klinikum der Universität München, Marchioninistr. 15, D-81377, München, Deutschland.
| | - Norma Jung
- Klinik für Innere Medizin I, Universitätsklinik Köln, Köln, Deutschland
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Description of a pharmacist-driven safety algorithm in Staphylococcus aureus bacteremia: Compliance, interventions, and good saves. Infect Control Hosp Epidemiol 2020; 41:921-925. [PMID: 32539873 DOI: 10.1017/ice.2020.143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate the impact of a pharmacist-driven Staphylococcus aureus bacteremia (SAB) safety bundle supported by leadership and to compare compliance before and after implementation. DESIGN Retrospective cohort study with descriptive and before-and-after analyses. SETTING Tertiary-care academic medical center. PATIENTS All patients with documented SAB, regardless of the source of infection, were included. Patients transitioned to palliative care were excluded from before-and-after analysis. METHODS A pharmacist-driven safety bundle including documented clearance of bacteremia, echocardiography, removal of central venous catheters, and targeted intravenous therapy of at least 2 weeks duration was implemented in November 2015 and was supported by leadership with stepwise escalation for nonresponse. A descriptive analysis of all patients with SAB during the study period included pharmacy interventions, acceptance rates, and escalation rates. A pre-post implementation analysis of 100 sequential patients compared bundle compliance and descriptive parameters. RESULTS Overall, 391 interventions were made in the 20-month period following implementation, including 20 "good saves" avoiding potentially major adverse events. No statistically significant differences in complete bundle compliance were detected between the periods (74% vs 84%; P = .08). However, we detected a significant increase in echocardiography after the bundle was implemented (83% vs 94%; P = .02) and fewer patients received suboptimal definitive therapy after the bundle was implemented (10% vs 3%; P = .045). CONCLUSIONS This pharmacist-driven SAB safety bundle with leadership support showed improvement in process measures, which may have prevented major adverse events, even with available infectious diseases (ID) consultation. It provides a critical safety net for institutions without mandatory ID consultation or with limited antimicrobial stewardship resources.
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Arensman K, Dela-Pena J, Miller JL, LaChance E, Beganovic M, Anderson M, Rivelli A, Wieczorkiewicz SM. Impact of Mandatory Infectious Diseases Consultation and Real-time Antimicrobial Stewardship Pharmacist Intervention on Staphylococcus aureus Bacteremia Bundle Adherence. Open Forum Infect Dis 2020; 7:ofaa184. [PMID: 32548206 PMCID: PMC7288607 DOI: 10.1093/ofid/ofaa184] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 05/19/2020] [Indexed: 12/22/2022] Open
Abstract
Background The purpose of this study was to evaluate the impact of infectious diseases consultation (IDC) and a real-time antimicrobial stewardship (AMS) review on the management of Staphylococcus aureus bacteremia (SAB). Methods This retrospective study included adult inpatients with SAB from January 2016 to December 2018 at 7 hospitals. Outcomes were compared between 3 time periods: before mandatory IDC and AMS review (period 1), after mandatory IDC and before AMS review (period 2), and after mandatory IDC and AMS review (period 3). The primary outcome was bundle adherence, defined as appropriate intravenous antimicrobial therapy, appropriate duration of therapy, appropriate surveillance cultures, echocardiography, and removal of indwelling intravenous catheters, if applicable. Secondary end points included individual bundle components, source control, length of stay (LOS), 30-day bacteremia-related readmission, and in-hospital all-cause mortality. Results A total of 579 patients met inclusion criteria for analysis. Complete bundle adherence was 65% in period 1 (n = 241/371), 54% in period 2 (n = 47/87), and 76% in period 3 (n = 92/121). Relative to period 3, bundle adherence was significantly lower in period 1 (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.37–0.93; P = .02) and period 2 (OR, 0.37; 95% CI, 0.20–0.67; P = .0009). No difference in bundle adherence was noted between periods 1 and 2. Significant differences were seen in obtaining echocardiography (91% vs 83% vs 100%; P < .001), source control (34% vs 45% vs 45%; P = .04), and hospital LOS (10.5 vs 8.9 vs 12.0 days; P = .01). No differences were noted for readmission or mortality. Conclusions The addition of AMS pharmacist review to mandatory IDC was associated with significantly improved quality care bundle adherence.
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Affiliation(s)
- Kellie Arensman
- Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | | | - Jessica L Miller
- Advocate South Suburban Hospital, Hazel Crest, Illinois, USA.,Advocate Trinity Hospital, Chicago, Illinois, USA
| | - Erik LaChance
- Advocate Illinois Masonic Medical Center, Chicago, Illinois, USA
| | - Maya Beganovic
- Advocate Lutheran General Hospital, Park Ridge, Illinois, USA
| | - Morgan Anderson
- Advocate Condell Medical Center, Libertyville, Illinois, USA.,Advocate Good Shepherd Hospital, Barrington, Illinois, USA
| | - Anne Rivelli
- Russel Center for Research and Innovation, Park Ridge, Illinois, USA
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Church DL, Naugler C. Essential role of laboratory physicians in transformation of laboratory practice and management to a value-based patient-centric model. Crit Rev Clin Lab Sci 2020; 57:323-344. [PMID: 32180485 DOI: 10.1080/10408363.2020.1720591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The laboratory is a vital part of the continuum of patient care. In fact, there are few programs in the healthcare system that do not rely on ready access and availability of complex diagnostic laboratory services. The existing transactional model of laboratory "medical practice" will not be able to meet the needs of the healthcare system as it rapidly shifts toward value-based care and precision medicine, which demands that practice be based on total system indicators, clinical effectiveness, and patient outcomes. Laboratory "value" will no longer be focused primarily on internal testing quality and efficiencies but rather on the relative cost of diagnostic testing compared to direct improvement in clinical and system outcomes. The medical laboratory as a "business" focused on operational efficiency and cost-controls must transform to become an essential clinical service that is a tightly integrated equal partner in direct patient care. We would argue that this paradigm shift would not be necessary if laboratory services had remained a "patient-centric" medical practice throughout the last few decades. This review is focused on the essential role of laboratory physicians in transforming laboratory practice and management to a value-based patient-centric model. Value-based practice is necessary not only to meet the challenges of the new precision medicine world order but also to bring about sustainable healthcare service delivery.
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Affiliation(s)
- Deirdre L Church
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Christopher Naugler
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, University of Calgary, Calgary, AB, Canada.,Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
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Impact of Infectious Diseases Consultation on the Treatment of Staphylococcus aureus Bacteremia. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2020. [DOI: 10.1097/ipc.0000000000000799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Goto M, Jones MP, Schweizer ML, Livorsi DJ, Perencevich EN, Richardson K, Beck BF, Alexander B, Ohl ME. Association of Infectious Diseases Consultation With Long-term Postdischarge Outcomes Among Patients With Staphylococcus aureus Bacteremia. JAMA Netw Open 2020; 3:e1921048. [PMID: 32049296 DOI: 10.1001/jamanetworkopen.2019.21048] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
IMPORTANCE Staphylococcus aureus bacteremia (SAB) is common and associated with poor long-term outcomes. Previous studies have demonstrated an association between infectious diseases (ID) consultation and improved short-term (ie, within 90 days) outcomes for patients with SAB, but associations with long-term outcomes are unknown. OBJECTIVE To investigate the association of ID consultation with long-term (ie, 5 years) postdischarge outcomes among patients with SAB. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all patients (N = 31 002) with a first episode of SAB who were discharged alive from 116 acute care units of the nationwide Veterans Health Administration where ID consultation was offered. Data were collected from January 2003 to December 2014, with follow-up through September 30, 2018. Data analysis was conducted from February to December 2019. EXPOSURES Infectious diseases consultation during the index hospital stay. MAIN OUTCOMES AND MEASURES The primary outcome was time to development of a composite event of all-cause mortality or recurrence of SAB within 5 years of discharge. As secondary outcomes, SAB recurrence and all-cause mortality with and without recurrence were analyzed while accounting for semicompeting risks. RESULTS The cohort included 31 002 patients (30 265 [97.6%] men; median [interquartile range] age at SAB onset, 64.0 [57.0-75.0] years). Among 31 002 patients, there were 18 794 (60.6%) deaths, 4772 (15.4%) SAB recurrences, and 20 414 (65.8%) composite events during 5 years of follow-up; 12 773 deaths (68.0%) and 2268 recurrences (47.5%) occurred more than 90 days after discharge. Approximately half of patients (15 360 [49.5%]) received ID consultation during the index hospital stay; ID consultation was associated with prolonged improvement in the composite outcome (adjusted hazard ratio at 5 years, 0.71; 95% CI, 0.68-0.74; P < .001). Infectious diseases consultation was also associated with improved outcomes when all-cause mortality without recurrence and SAB recurrence were analyzed separately (all-cause mortality without recurrence: adjusted hazard ratio at 5 years, 0.77; 95% CI, 0.74-0.81; P < .001; SAB recurrence: adjusted hazard ratio at 5 years, 0.68; 95% CI, 0.64-0.72; P < .001). CONCLUSIONS AND RELEVANCE Having an ID consultation during the index hospital stay among patients with SAB was associated with improved postdischarge outcomes for at least 5 years, suggesting that contributions of ID specialists to management during acute infection may have a substantial influence on long-term outcomes. Further investigations of the association of ID consultation with outcomes after S aureus should include long-term follow-up.
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Affiliation(s)
- Michihiko Goto
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Michael P Jones
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City
| | - Marin L Schweizer
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Daniel J Livorsi
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Eli N Perencevich
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
| | - Kelly Richardson
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Brice F Beck
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Bruce Alexander
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
| | - Michael E Ohl
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City
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14
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Wee LE, Tan AL, Wijaya L, Chlebicki MP, Thumboo J, Tan BH. Timeliness of Infectious Diseases Referral and Inappropriate Antibiotic Usage Post-Referral in an Asian Tertiary Hospital. Trop Med Infect Dis 2019; 4:tropicalmed4040137. [PMID: 31752072 PMCID: PMC6958425 DOI: 10.3390/tropicalmed4040137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Revised: 11/11/2019] [Accepted: 11/14/2019] [Indexed: 11/16/2022] Open
Abstract
Infectious diseases (ID) specialists advise on complicated infections and are advocates for the interventions of antibiotic stewardship programs (ASP). Early referral to ID specialists has been shown to improve patient outcomes; however, not all referrals to ID specialists are made in a timely fashion. A retrospective cross-sectional study of all referrals to ID specialists in a Singaporean tertiary hospital was conducted from January 2016 to January 2018. The following quality indicators were examined: early referral to ID specialists (within 48 h of admission) and ASP intervention for inappropriate antibiotic usage, even after referral to ID specialists. Chi-square was used for univariate analysis and logistic regression for multivariate analysis. A total of 6490 referrals over the 2-year period were analysed; of those, 36.7% (2384/6490) were from surgical disciplines, 47.0% (3050/6490) were from medical disciplines, 14.2% (922/6490) from haematology/oncology and 2.1% (134/6490) were made to the transplant ID service. Haematology/oncology patients and older patients (aged ≥ 60 years) had lower odds of early referral to ID specialists but higher odds of subsequent ASP intervention for inappropriate antibiotic usage, despite prior referral to an ID specialist. Elderly patients and haematology/oncology patients can be referred to ID specialists earlier and their antimicrobial regimens further optimised, perhaps by fostering closer cooperation between ID specialists and primary physicians.
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Affiliation(s)
- Liang En Wee
- Duke-NUS Graduate Medical School, 8 College Road, Singapore 169857, Singapore
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
- Correspondence: ; Tel.: +65-9677-7651
| | - Aidan Lyanzhiang Tan
- Preventive Medicine Residency, National University Health System, 1E Kent Ridge Rd, Singapore 119228, Singapore;
| | - Limin Wijaya
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
| | - Maciej Piotr Chlebicki
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
| | - Julian Thumboo
- Department of Rheumatology, Singapore General Hospital, Outram Road, Singapore 169608, Singapore;
- Health Services Research Unit, Singapore General Hospital, Outram Road, Singapore 169608, Singapore
| | - Ban Hock Tan
- Department of Infectious Diseases, Singapore General Hospital, Outram Road, Singapore 169608, Singapore; (L.W.); (M.P.C.); (B.H.T.)
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15
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Yamada K, Imoto W, Yamairi K, Shibata W, Namikawa H, Yoshii N, Fujimoto H, Nakaie K, Okada Y, Fujita A, Kawaguchi H, Shinoda Y, Nakamura Y, Kaneko Y, Yoshida H, Kakeya H. The intervention by an antimicrobial stewardship team can improve clinical and microbiological outcomes of resistant gram-negative bacteria. J Infect Chemother 2019; 25:1001-1006. [PMID: 31255524 DOI: 10.1016/j.jiac.2019.05.026] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/11/2019] [Accepted: 05/25/2019] [Indexed: 11/16/2022]
Abstract
Antibiotic stewardship (AS) improves patient outcomes and rates of antibiotic susceptibilities. However, the long-term effect of AS programs (ASPs) on mortality is unclear. This study aimed to assess the impact of bedside interventions by an AS team (AST) on clinical and microbiological outcomes. This retrospective study enrolled patients with bloodstream infections (BSI) and long-term use of broad-spectrum antibiotics (more than 7 days). The main outcomes were 30-day and in-hospital mortality of patients with BSI. The secondary outcomes were the day of therapy (DOT) and susceptibility of antipseudomonal agents. Cases were classified into two groups: the pre-ASP group comprised cases between 2011 and 2013 and the post-ASP group, between 2014 and 2016. The outcomes were then compared between the two groups. Among the patients with all BSI (n = 1187), no significant differences in 30-day mortality were observed between those in the pre-ASP and post-ASP groups. However, in-hospital mortality was significantly lower in the post-ASP group than that in the pre-ASP group (24.8% vs. 18.0%; P = 0.004). Furthermore, the 30-day and in-hospital mortality of resistant gram-negative bacteraemia was significantly lower (20.4% vs.10.5%; P = 0.04 and 28.0% vs.16.1%; P = 0.03). The DOT of broad-spectrum antibiotics decreased except that of tazobactam/piperacillin. The susceptibilities of tazobactam/piperacillin, ceftazidime, cefepime, sulbactam/cefoperazone, gentamicin, ciprofloxacin levofloxacin, imipenem and meropenem were significantly better. Interventions by the AST can improve the clinical and microbiological outcomes, especially resistant gram-negative bacteria. Furthermore, this effect of our ASP can continue for a long term.
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Affiliation(s)
- Koichi Yamada
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Waki Imoto
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Kazushi Yamairi
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Wataru Shibata
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Hiroki Namikawa
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Naoko Yoshii
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Hiroki Fujimoto
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Kiyotaka Nakaie
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Yasuyo Okada
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Akiko Fujita
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Hiroshi Kawaguchi
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Yoshikatsu Shinoda
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Yasutaka Nakamura
- Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Yukihiro Kaneko
- Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Bacteriology, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585 Japan
| | - Hisako Yoshida
- Department of Medical Statistics, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan
| | - Hiroshi Kakeya
- Department of Infection Control Science, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Department of Infection Control and Prevention, Osaka City University Hospital, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan; Research Center for Infectious Diseases, Graduate School of Medicine, Osaka City University, 1-4-3, Asahi-machi, Abeno-ku, Osaka-shi, Osaka, 545-8585, Japan.
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Chastain DB, Cluck DB, Stover KR, Lusardi KT, Marx A, Green S, Faulkner-Fennell C, Turner M, Chahine EB, Bookstaver PB, Bland CM. A Baker's Dozen of Top Antimicrobial Stewardship Intervention Publications in 2017. Open Forum Infect Dis 2019; 6:ofz133. [PMID: 31041343 PMCID: PMC6483124 DOI: 10.1093/ofid/ofz133] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Accepted: 03/21/2019] [Indexed: 12/01/2022] Open
Abstract
With an increasing number of antimicrobial stewardship-related articles published each year, attempting to stay current is challenging. The Southeastern Research Group Endeavor (SERGE-45) identified antimicrobial stewardship-related peer-reviewed literature that detailed an "actionable" intervention for 2017. The top 13 publications were selected using a modified Delphi technique. These manuscripts were reviewed to highlight the "actionable" intervention used by antimicrobial stewardship programs to provide key stewardship literature for training and teaching and identify potential intervention opportunities within their institutions.
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Affiliation(s)
| | - David B Cluck
- Bill Gatton College of Pharmacy, East Tennessee State University, Johnson City, Tennessee
| | - Kayla R Stover
- University of Mississippi School of Pharmacy, Jackson, Mississippi
| | | | - Ashley Marx
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Sarah Green
- Novant Health Forsyth Medical Center, Winston-Salem, North Carolina
| | | | | | - Elias B Chahine
- Lloyd L. Gregory School of Pharmacy, Palm Beach Atlantic University, West Palm Beach, Florida
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17
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Remtulla S, Zurek K, Cervera C, Hernandez C, Lee MC, Hoang HL. Impact of an Unsolicited, Standardized Form-Based Antimicrobial Stewardship Intervention to Improve Guideline Adherence in the Management of Staphylococcus aureus Bacteremia. Open Forum Infect Dis 2019; 6:ofz098. [PMID: 30949538 PMCID: PMC6441557 DOI: 10.1093/ofid/ofz098] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 02/22/2019] [Indexed: 01/21/2023] Open
Abstract
Background Antimicrobial stewardship programs (ASPs) improve Staphylococcus aureus bacteremia (SAB) management. The objective of the current study was to evaluate the effect of unsolicited prospective audit and feedback (PAF) using a standardized SAB bundle form on the management of SAB. Methods Multicenter, pre-post quasi-experimental study of inpatients with SAB. The ASP developed an evidence-based SAB management bundle that included recommendations for infectious diseases consultation, blood culture clearance, appropriate empiric and definitive therapy, echocardiography, adequate treatment duration, and source control where applicable. ASP pharmacists performed PAF using a standardized form outlining bundle components. The primary outcome was bundle component adherence. Secondary outcomes were length of stay, 30-day readmission rate, and in-hospital and 30-day mortality rates. Results A total of 199 patients were included (preintervention group, 62; intervention group, 137). Bundle implementation with PAF resulted in significant improvements in infectious diseases consultation (56.5% in preintervention vs 93.4% in intervention group), appropriate definitive antibiotic therapy (83.9% vs 99.3%), ordering echocardiography (72.6% vs 95.6%), and adequate treatment duration (87.0% vs 100%) (all P < .001). Overall bundle adherence increased by 43.8% (P < .001). Readmission and 30-day mortality rates decreased, but this difference did not reach statistical significance. Conclusions Unsolicited PAF using a standardized SAB management bundle significantly improved adherence to evidence-based recommendations. This simple yet effective ASP-driven intervention can ensure consistent management of a highly morbid infection.
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Affiliation(s)
| | | | | | | | | | - Holly L Hoang
- Covenant Health, Edmonton, Canada.,University of Alberta, Edmonton, Canada
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18
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Kalimuddin S, Chan YFZ, Phillips R, Ong SP, Archuleta S, Lye DC, Tan TT, Low JGH. A randomized phase 2B trial of vancomycin versus daptomycin for the treatment of methicillin-resistant Staphylococcus aureus bacteremia due to isolates with high vancomycin minimum inhibitory concentrations - results of a prematurely terminated study. Trials 2018; 19:305. [PMID: 29859132 PMCID: PMC5984763 DOI: 10.1186/s13063-018-2702-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 05/21/2018] [Indexed: 01/18/2023] Open
Abstract
Background Studies have suggested the reduced effectiveness of vancomycin against methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections with high vancomycin minimum inhibitory concentrations. Alternative agents such as daptomycin may be considered. We conducted a randomized controlled study comparing daptomycin against vancomycin in the treatment of MRSA bloodstream infections with high vancomycin minimum inhibitory concentrations. Methods Patients were randomized to receive vancomycin or daptomycin for a minimum of 14 days. The primary end point was the rate of all-cause mortality at day 60. Results A total of 14 patients were randomized in this study, with 7 patients in each treatment arm. The study was terminated early due to slow patient accrual. At day 60, there was one death in the vancomycin arm and none in the daptomycin arm. The median time to microbiological clearance was 4 days in both arms (IQR 3–5 days in the vancomycin arm and 3–7 days in daptomycin arm). Only one patient in the vancomycin arm had recurrence of bacteremia. Rates of adverse events were similar in both arms. There was one case of musculoskeletal toxicity and one case of drug-related nephrotoxicity - both events occurred in the daptomycin arm. None of the patients in either treatment arm required cessation of study treatment or addition of a second anti-MRSA agent because of worsening infection. Conclusion Based on the limited number of patients evaluated in this study, it remains unclear if alternative, more expensive agents such as daptomycin are superior to vancomycin in the treatment of high vancomycin minimum inhibitory concentration MRSA bloodstream infections. More studies are urgently needed but investigators may wish to consider employing novel, alternative trial methodologies to ensure a greater chance of success. Trial registration ClinicalTrials.gov, NCT01975662. Registered on 5 November 2013.
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Affiliation(s)
- Shirin Kalimuddin
- Department of Infectious Diseases, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore.
| | - Yvonne F Z Chan
- Department of Infectious Diseases, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Rachel Phillips
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Guy's Campus, London, SE1 1UL, UK.,NIHR Biomedical Research Centre at Guy's and St. Thomas' NHS Foundation Trust and King's College London, Guy's Hospital, London, SE1 9RT, UK
| | - Siew Pei Ong
- Geriatric Education and Research Institute, 2 Yishun Central 2, Singapore, 768024, Singapore
| | - Sophia Archuleta
- Division of Infectious Diseases, National University Health System, 5 Lower Kent Ridge Rd, Singapore, 119074, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, 21 Lower Kent Ridge Rd, Singapore, 119077, Singapore
| | - David Chien Lye
- Department of Infectious Diseases, Communicable Disease Centre, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Thuan Tong Tan
- Department of Infectious Diseases, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
| | - Jenny G H Low
- Department of Infectious Diseases, Singapore General Hospital, 20 College Road, Singapore, 169856, Singapore
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19
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Wenzler E, Wang F, Goff DA, Prier B, Mellett J, Mangino JE, Bauer KA. An Automated, Pharmacist-Driven Initiative Improves Quality of Care for Staphylococcus aureus Bacteremia. Clin Infect Dis 2018; 65:194-200. [PMID: 28379326 DOI: 10.1093/cid/cix315] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Accepted: 03/31/2017] [Indexed: 01/07/2023] Open
Abstract
Background Infectious diseases (ID) consultation and antimicrobial stewardship intervention have been shown to improve the management of Staphylococcus aureus bacteremia (SAB). As the workload of antimicrobial stewardship programs (ASPs) continues to increase, ASPs must find a way to maximize the efficiency of the program while optimizing patient outcomes. The objective of this study was to evaluate the impact of incorporating health informatics into the management of SAB via a pharmacist-driven initiative. Methods Retrospective, single-center quasi-experimental study of hospitalized patients with SAB. During the intervention period, pharmacists were alerted to patients with SAB via a patient scoring tool integrated into the electronic medical record. Pharmacists utilized the scoring tool and the institution's evidence-based practice guideline to make standardized recommendations to promote adherence to SAB quality-of-care measures and encourage ID consultation. The primary outcome was overall compliance along with adherence to individual quality-of-care components. Secondary clinical outcomes were also analyzed. Results In sum, 84 patients were identified for study inclusion, 45 in the pre-intervention and 39 in the intervention group. As a whole, all 4 quality-of-care components for the management of SAB were significantly more frequently adhered to in the intervention group (68.9% vs 92.3%; P = .008). The incidence of ID consult improved significantly by almost 20% in the intervention group (75.6% vs 94.9%, P = .015). No statistically significant differences in duration of bacteremia, length-of-stay, infection-related length-of-stay, or readmission were observed between the groups. The incidence of all-cause mortality was 6-fold higher in the pre- intervention group compared to the intervention group (15.6% vs 2.6%, P = .063). Conclusion An automated, pharmacist-driven intervention for the management of patients with SAB demonstrated a significant improvement in patients receiving an ID consult, targeted antimicrobial therapy, and adherence to all SAB quality-of-care measures. As antimicrobial stewardship becomes a mandatory aspect of healthcare in all hospitals in the United States, ASPs will be forced to find ways to provide more efficient, impactful, disease state-based patient care. Our study provides the framework for and data to support this intervention in one of the most clinically important infectious diseases.
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Affiliation(s)
- Eric Wenzler
- College of Pharmacy, University of Illinois at Chicago
| | | | | | | | | | - Julie E Mangino
- Internal Medicine, Division of Infectious Diseases, The Ohio State University Wexner Medical Center, Columbus
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20
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Kim I, Kim WY, Jeoung ES, Lee K. Current Status and Survival Impact of Infectious Disease Consultation for Multidrug-Resistant Bacteremia in Ventilated Patients: A Single-Center Experience in Korea. Acute Crit Care 2018; 33:73-82. [PMID: 31723866 PMCID: PMC6849055 DOI: 10.4266/acc.2017.00591] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Revised: 02/28/2018] [Accepted: 03/14/2018] [Indexed: 12/15/2022] Open
Abstract
Background We evaluated the current status and survival impact of infectious disease consultation (IDC) in ventilated patients with multidrug-resistant (MDR) bacteremia. Methods One hundred sixty-one consecutive patients from a single tertiary care hospital were enrolled over a 5-year period. Patients with at least one of the following six MDR bacteremias were included: methicillin-resistant Staphylococcus aureus, extended-spectrum β-lactamase-producing gram-negative bacteria (Escherichia coli and Klebsiella pneumonia), carbapenem-resistant gram-negative rods (Acinetobacter baumannii and Pseudomonas aeruginosa), and vancomycin-resistant Enterococcus faecium. Results Median patient age was 66 years (range, 18 to 95), and 57.8% of subjects were male. The 28-day mortality after the day of blood culture was 52.2%. An IDC was requested for 96 patients based on a positive blood culture (59.6%). Patients without IDC had significantly higher rate of hemato-oncologic diseases as a comorbidity (36.9% vs. 11.5%, P < 0.001). Patients without an IDC had higher Acute Physiology and Chronic Health Evaluation (APACHE) II score (median, 20; range, 8 to 38 vs. median, 16; range, 5 to 34, P < 0.001) and Sequential Organ Failure Assessment (SOFA) score (median, 9; range, 2 to 17 vs. median, 7; range, 2 to 20; P = 0.020) on the day of blood culture and a higher 28-day mortality rate (72.3% vs. 38.5%, P < 0.001). In patients with SOFA ≥9 (cut-off level based on Youden's index) on the day of blood culture and gram-negative bacteremia, IDC was also significantly associated with lower 28-day mortality (hazard ratio [HR], 0.298; 95% confidence interval [CI], 0.167 to 0.532 and HR, 0.180; 95% CI, 0.097 to 0.333; all P < 0.001) based on multivariate Cox regression analysis. Conclusions An IDC for MDR bacteremia was requested less often for ventilated patients with greater disease severity and higher 28-day mortality after blood was drawn. In patients with SOFA ≥9 on the day of blood culture and gram-negative bacteremia, IDC was associated with improved 28-day survival after blood draw for culture.
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Affiliation(s)
- Insu Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Won-Young Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Eun Suk Jeoung
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
| | - Kwangha Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea
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21
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Impact of rapid identification of Staphylococcus aureus bloodstream infection without antimicrobial stewardship intervention on antibiotic optimization and clinical outcomes. Diagn Microbiol Infect Dis 2017; 89:125-130. [PMID: 28802758 DOI: 10.1016/j.diagmicrobio.2017.07.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/23/2017] [Accepted: 07/01/2017] [Indexed: 02/02/2023]
Abstract
Few studies have evaluated the clinical impact of polymerase chain reaction (PCR) for Staphylococcus aureus bloodstream infections in resource-limited settings that lack direct antimicrobial stewardship intervention. This retrospective cohort study compared patients with standard microbiological identification (n=343) to those with additional identification by (PCR) (n=130). Time to initiation of optimal therapy was similar between groups but substantially shorter in the PCR group for those infected with methicillin susceptible S. aureus (median 40.0h vs. 28.3h, P=0.001). After controlling for confounding factors including infectious diseases consultation, the PCR group had a shorter time to initiation of optimal therapy by 9.7h (95% CI 4.3-15.0h). Clinical outcomes were similar in the non-PCR and PCR groups. While time to initiation of optimal therapy was shorter in the PCR group, greater reductions may be realized through additional education, direct antimicrobial stewardship intervention, or additional clinician notification.
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22
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Weis S, Kimmig A, Hagel S, Pletz MW. [Antibiotic stewardship and Staphylococcus aureus Bacteremia]. Med Klin Intensivmed Notfmed 2017; 112:192-198. [PMID: 28378151 DOI: 10.1007/s00063-017-0270-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 02/13/2017] [Indexed: 01/01/2023]
Abstract
Rates of antibiotic resistance are increasing worldwide and impact on the treatment of patients with bacterial infections. A broad and uncritical application in inpatient and outpatient settings as well as in agriculture has been recognized as the main driving force. Antibiotic stewardship (ABS) programs aim at countering this worrisome development using various direct interventions such as infectious disease counseling. Blood stream infections caused by Staphylococcus (S.) aureus are severe infections associated with high mortality rates. ABS interventions such as de-eskalation of the antibiotic regimen or application of narrow-spectrum beta-lactam antibiotics can significantly reduce mortality rates. In this review, we discuss the importance of ABS programs and infectious disease counseling for the treatment of S. aureus blood stream infection.
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Affiliation(s)
- S Weis
- Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland.
- Center for Sepsis Control and Care, Universitätsklinikum Jena, Jena, Deutschland.
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Jena, Jena, Deutschland.
| | - A Kimmig
- Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
| | - S Hagel
- Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
- Center for Sepsis Control and Care, Universitätsklinikum Jena, Jena, Deutschland
| | - M W Pletz
- Zentrum für Infektionsmedizin und Krankenhaushygiene, Universitätsklinikum Jena, Am Klinikum 1, 07740, Jena, Deutschland
- Center for Sepsis Control and Care, Universitätsklinikum Jena, Jena, Deutschland
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Berrevoets MAH, Kouijzer IJE, Aarntzen EHJG, Janssen MJR, De Geus-Oei LF, Wertheim HFL, Kullberg BJ, Oever JT, Oyen WJG, Bleeker-Rovers CP. 18F-FDG PET/CT Optimizes Treatment in Staphylococcus Aureus Bacteremia and Is Associated with Reduced Mortality. J Nucl Med 2017; 58:1504-1510. [PMID: 28336786 DOI: 10.2967/jnumed.117.191981] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Accepted: 03/13/2017] [Indexed: 12/26/2022] Open
Abstract
Metastatic infection is an important complication of Staphylococcus aureus bacteremia (SAB). Early diagnosis of metastatic infection is crucial, because specific treatment is required. However, metastatic infection can be asymptomatic and difficult to detect. In this study, we investigated the role of 18F-FDG PET/CT in patients with SAB for detection of metastatic infection and its consequences for treatment and outcome. Methods: All patients with SAB at Radboud University Medical Center were included between January 2013 and April 2016. Clinical data and results of 18F-FDG PET/CT and other imaging techniques, including echocardiography, were collected. Primary outcomes were newly diagnosed metastatic infection by 18F-FDG PET/CT, subsequent treatment modifications, and patient outcome. Results: A total of 184 patients were included, and 18F-FDG PET/CT was performed in 105 patients, of whom 99 had a high-risk bacteremia. 18F-FDG PET/CT detected metastatic infectious foci in 73.7% of these high-risk patients. In 71.2% of patients with metastatic infection, no signs and symptoms suggesting metastatic complications were present before 18F-FDG PET/CT was performed. 18F-FDG PET/CT led to a total of 104 treatment modifications in 74 patients. Three-month mortality was higher in high-risk bacteremia patients without 18F-FDG PET/CT performed than in those in whom 18F-FDG PET/CT was performed (32.7% vs. 12.4%, P = 0.003). In multivariate analysis, 18F-FDG PET/CT was the only factor independently associated with reduced mortality (P = 0.005; odds ratio, 0.204; 95% confidence interval, 0.066-0.624). A higher comorbidity score was independently associated with increased mortality (P = 0.003; odds ratio, 1.254; 95% confidence interval, 1.078-1.457). Conclusion:18F-FDG PET/CT is a valuable technique for early detection of metastatic infectious foci, often leading to treatment modification. Performing 18F-FDG PET/CT is associated with significantly reduced 3-mo mortality.
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Affiliation(s)
- Marvin A H Berrevoets
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ilse J E Kouijzer
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Erik H J G Aarntzen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marcel J R Janssen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Lioe-Fee De Geus-Oei
- Department of Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands.,MIRA Institute for Biomedical Technology and Technical Medicine, Biomedical Photonic Imaging Group, University of Twente, Enschede, The Netherlands
| | - Heiman F L Wertheim
- Department of Medical Microbiology and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - Bart-Jan Kullberg
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jaap Ten Oever
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Wim J G Oyen
- Department of Radiology and Nuclear Medicine, Radboud University Medical Center, Nijmegen, The Netherlands.,Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Chantal P Bleeker-Rovers
- Department of Internal Medicine and Radboud Center for Infectious Diseases, Radboud University Medical Center, Nijmegen, The Netherlands
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The "Choosing Wisely" initiative in infectious diseases. Infection 2017; 45:263-268. [PMID: 28290130 DOI: 10.1007/s15010-017-0997-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 02/17/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE "Choosing Wisely" is a growing international campaign aiming at practice changes to improve patient health and safety by both, conduct of essential and avoidance of unnecessary diagnostic, preventive and therapeutic procedures. The goal is to create an easily recognizable and distributable list ("Choosing Wisely items") that addresses common over- and underuse in the management of infectious diseases. METHODS The German Society of Infectious Diseases (DGI) participates in the campaign "Klug Entscheiden" by the German Society of Internal Medicine. Committee members of the (DGI) listed potential 'Choosing Wisely items'. Topics were subjected to systematic evidence review and top ten items were selected for appropriateness. Five positive and negative recommendations were approved via individual member vote. RESULTS The final recommendations are: (1) Imperatively start antimicrobial treatment and remove the focus in Staphylococcus aureus bloodstream infection. (2) Critically ill patients with signs of infection need early appropriate antibiotic therapy. (3) Annual influenza vaccination should be given to individuals with age >60 years, patients with specific co-morbidities and to contact persons who may spread influenza to others. (4) All children should receive measles vaccine. (5) Prefer oral formulations of highly bioavailable antimicrobials whenever possible. (6) Avoid prescribing antibiotics for uncomplicated upper respiratory tract infections. (7) Do not treat asymptomatic bacteriuria with antibiotics. (8) Do not treat Candida detected in respiratory or gastrointestinal tract specimens. (9) Do not prolong prophylactic administration of antibiotics in patients after they have left the operating room. (10) Do not treat an elevated C-reactive protein (CRP) or procalcitonin with antibiotics for patients without signs of infection. CONCLUSIONS Physicians will reduce potential harm to patients and increase the value of health care when implementing these recommendations.
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Complete adherence to evidence-based quality-of-care indicators for Staphylococcus aureus bacteremia resulted in better prognosis. Infection 2016; 45:83-91. [DOI: 10.1007/s15010-016-0946-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 09/17/2016] [Indexed: 12/31/2022]
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26
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Impact of Infectious Diseases Consultation on Clinical Outcomes of Patients with Staphylococcus aureus Bacteremia in a Community Health System. Antimicrob Agents Chemother 2016; 60:5682-7. [PMID: 27401580 DOI: 10.1128/aac.00439-16] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 07/07/2016] [Indexed: 12/19/2022] Open
Abstract
Staphylococcus aureus bacteremia (SAB) causes high rates of morbidity and death. Several studies in academic health settings have demonstrated that consultations from infectious diseases specialists improve the quality of care and clinical outcomes for SAB. Few data that describe the impact in resource-limited settings such as community hospitals are available. This retrospective cohort study evaluated the adherence to quality-of-care indicators and the clinical outcomes for SAB in a five-hospital community health system (range of 95 to 272 available beds per hospital), for patients with versus without infectious diseases consultation (IDC). IDC was provided if requested by the attending physician. The primary outcome was the incidence of treatment failure, defined as 30-day in-hospital death or 90-day SAB recurrence. Other outcomes included adherence to quality-of-care indicators. A total of 473 adult patients with SAB were included, with 369 (78%) receiving IDC. We identified substantial differences in baseline characteristics between the IDC group and the no-IDC group, including greater incidences of complicated bacteremia and intravenous drug users in the IDC group, with similar rates of severe illness (measured by Pitt bacteremia scores). Adherence to quality-of-care indicators was greater for patients with IDC (P < 0.001). After adjustment for other predicting variables, IDC was associated with a lower rate of treatment failure (adjusted odds ratio, 0.42 [95% confidence interval, 0.20 to 0.86]; P = 0.018). IDC provided better quality of care and better clinical outcomes for patients with SAB who were treated at small, resource-limited, community hospitals.
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27
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So M, Yang DY, Bell C, Humar A, Morris A, Husain S. Solid organ transplant patients: are there opportunities for antimicrobial stewardship? Clin Transplant 2016; 30:659-68. [PMID: 26992472 DOI: 10.1111/ctr.12733] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2016] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Rising incidence of Clostridium difficile and multidrug-resistant organisms' infections and a dwindling development of new antimicrobials are an impetus for antimicrobial stewardship in organ transplant recipients. We sought to understand antimicrobial prescribing practices and identify opportunities for interdisciplinary collaboration among the transplant, antimicrobial stewardship, and infectious diseases teams. METHODS In 2013, two assessors conducted four real-time audits on all antimicrobial therapy in transplant patients, assessing each regimen against stewardship principles established by the Centers for Disease Prevention and Control, supplemented by applicable transplant-specific infection guidelines. Chi-square test was used to compare stewardship-concordant and stewardship-discordant audit results relative to transplant infectious diseases consultation. RESULTS Analysis was performed on 176 audits. Fifty-eight percent (103/176) received at least one antimicrobial, of which 69.9% (72/103) were stewardship-concordant. Infections were confirmed or suspected in 52.3% (92/176). Of those, 98.9% (91/92) received antimicrobials, and 41.8% (38/91) were prescribed by transplant clinicians. Infectious diseases consultation was associated with more stewardship-concordant prescriptions (78.5% vs. 59.6%, p = 0.03). The most common stewardship-discordant categories were lack of de-escalation, empiric antimicrobial spectrum being too broad, and therapy duration being too long. CONCLUSIONS Opportunities exist for antimicrobial stewardship in transplant recipients, especially those who do not require infectious diseases consultation.
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Affiliation(s)
- Miranda So
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, 144 College Street, Toronto, ON, Canada
| | - Daisy Yu Yang
- Baycrest Health Sciences Centre, Toronto, ON, Canada
| | - Chaim Bell
- Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Atul Humar
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Andrew Morris
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shahid Husain
- University Health Network, 585 University Avenue, Toronto, ON, Canada.,Mount Sinai Hospital, Toronto, ON, Canada.,Department of Medicine, University of Toronto, Toronto, ON, Canada
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Paulsen J, Solligård E, Damås JK, DeWan A, Åsvold BO, Bracken MB. The Impact of Infectious Disease Specialist Consultation for Staphylococcus aureus Bloodstream Infections: A Systematic Review. Open Forum Infect Dis 2016; 3:ofw048. [PMID: 27047985 PMCID: PMC4817315 DOI: 10.1093/ofid/ofw048] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Indexed: 01/15/2023] Open
Abstract
Staphylococcus aureus is a common cause of severe bloodstream infection. We performed a systematic review to assess whether consultation with infectious disease specialists decreased all-cause mortality or rate of complications of S aureus bloodstream infections. The review also assessed parameters associated with the quality of management of the infection. We searched for eligible studies in PubMed, Embase, Scopus, and clinical trials.gov as well as the references of included studies. We identified 22 observational studies and 1 study protocol for a randomized trial. A meta-analysis was not performed because of the high risk of bias in the included studies. The outcomes are reported in a narrative review. Most included studies reported survival benefit, in the adjusted analysis. Recommended management strategies were carried out significantly more often among patients seen by an infectious disease specialist. Trials, such as cluster-randomized controlled trials, can more validly assess the studies at low risk of bias.
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Affiliation(s)
- Julie Paulsen
- Centre ofMolecular Inflammation Research, Department of Cancer Research and Molecular Medicine; Department of Medicine, Levanger Hospital, Nord-Trøndelag Hospital Trust; Mid-Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim
| | - Erik Solligård
- Departments ofCirculation and Medical Imaging; Mid-Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim; Clinic of Anaesthesia and Intensive Care
| | - Jan Kristian Damås
- Centre ofMolecular Inflammation Research, Department of Cancer Research and Molecular Medicine; Mid-Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim; Departments ofInfectious Diseases
| | - Andrew DeWan
- Department of Chronic Disease Epidemiology , Yale University School of Public Health , New Haven, Connecticut
| | - Bjørn Olav Åsvold
- Mid-Norway Sepsis Research Center, Norwegian University of Science and Technology, Trondheim; Public Health, Norwegian University of Science and Technology, Trondheim; Endocrinology, St Olavs Hospital, Trondheim University Hospital, Norway
| | - Michael B Bracken
- Department of Chronic Disease Epidemiology , Yale University School of Public Health , New Haven, Connecticut
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Townsend J, Pelletier J, Peterson G, Matulevicius S, Sreeramoju P. Quality Improvement of Staphylococcus aureus Bacteremia Management and Predictors of Relapse-free Survival. Am J Med 2016; 129:195-203. [PMID: 26519616 DOI: 10.1016/j.amjmed.2015.09.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Revised: 08/15/2015] [Accepted: 09/20/2015] [Indexed: 11/18/2022]
Abstract
PURPOSE The purpose of this study is to improve the quality of care and patient outcomes for Staphylococcus aureus bacteremia. METHODS A quasi-experimental pre- and postintervention study design was used to compare process and clinical endpoints before and after a quality-improvement initiative. All inpatients >18 years of age with a positive blood culture for S. aureus during the specified pre- and postintervention period with clinical information available in the electronic medical record were included. An institutional protocol for the care of patients with S. aureus bacteremia was developed, formalized, and distributed to providers using a pocket card, an electronic order set, and targeted lectures over a 9-month period. RESULTS There were 167 episodes of S. aureus bacteremia (160 patients) identified in the preintervention period, and 127 episodes (123 patients) in the postintervention period. Guideline adherence improved in the postintervention period for usage of transesophageal echocardiogram (43.9% vs 20.2%, P <.01) and adequate duration of intravenous therapy (71% vs 60%, P = .05). In a multivariate Cox proportional hazard model, the variables associated with increased relapse-free survival were postintervention period (hazard ratio [HR] 0.48; confidence interval [CI], 0.24-0.95; P .035) and appropriate source control (HR 0.53; CI, 0.24-0.92; P .027). Regardless of intervention, presence of cancer was associated with an increased risk of relapse or mortality at 90 days (HR 2.88; P <.0001; CI, 1.35-5.01). CONCLUSION A bundled educational intervention to promote adherence to published guidelines for the treatment of S. aureus bacteremia resulted in a significant improvement in provider adherence to guidelines as well as increased 90-day relapse-free survival.
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Affiliation(s)
- Jennifer Townsend
- Division of Internal Medicine-Infectious Diseases, University of Texas Southwestern, Dallas.
| | - Jamie Pelletier
- Department of Epidemiology, University of Texas Health Science Center School of Public Health, Dallas Campus
| | - Gail Peterson
- Division of Internal Medicine-Cardiology, University of Texas Southwestern, Dallas
| | - Susan Matulevicius
- Division of Internal Medicine-Cardiology, University of Texas Southwestern, Dallas
| | - Pranavi Sreeramoju
- Division of Internal Medicine-Infectious Diseases, University of Texas Southwestern, Dallas; Division of Clinical Quality Management, Parkland Health and Hospital System, Dallas, Texas
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30
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Infectious disease consultation for Staphylococcus aureus bacteremia - A systematic review and meta-analysis. J Infect 2015; 72:19-28. [PMID: 26453841 DOI: 10.1016/j.jinf.2015.09.037] [Citation(s) in RCA: 153] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/28/2015] [Accepted: 09/29/2015] [Indexed: 11/20/2022]
Abstract
OBJECTIVE Mortality and morbidity of Staphylococcus aureus bacteremia (SAB) still remains considerably high. We aimed to evaluate the impact of infectious disease consultation (IDC) on the management and outcomes of patients with SAB. METHODS We systematically searched 3 publication databases from inception to 31st May 2015 and reference lists of identified primary studies. RESULTS Our search returned 2874 reports, of which 18 fulfilled the inclusion criteria, accounting for 5337 patients. Overall 30-day mortality was 19.95% [95% CI 14.37-27.02] with a significant difference in favour of the IDC group (12.39% vs 26.07%) with a relative risk (RR) of 0.53 [95% CI 0.43-0.65]. 90-day mortality and relapse risk for SAB were also reduced significantly with RRs of 0.77 [95% CI 0.64-0.92] and 0.62 [95% CI 0.39-0.99], respectively. Both, the appropriateness of antistaphylococcal agent and treatment duration was improved by IDC (RR 1.14 [95% CI 1.08-1.20] and 1.85 [95% CI 1.39-2.46], respectively). Follow-up blood cultures and echocardiography were performed more frequently following IDC (RR 1.35 [95% CI 1.25-1.46] and 1.98 [95% CI 1.66-2.37], respectively). CONCLUSIONS Evidence-based clinical management enforced by IDC may improve outcome of patients with SAB. Well-designed cluster-randomized controlled trials are needed to confirm this finding from observational studies.
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Burden and spectrum of infectious disease in Germany 2009-2014: a multicentre study from Berlin's Municipal Hospitals. Infection 2015; 44:187-95. [PMID: 26311655 DOI: 10.1007/s15010-015-0834-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 08/17/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE This study aimed at assessing the burden and spectrum of infectious diseases (ID) in a Metropolitan population in Germany. METHODS A discharge database using ICD-10 codes enabled the identification of hospitalizations with infection-related diagnoses. All hospital admissions between 2009 and 2014 were analysed from 9 municipal hospitals serving approximately one-third of an urban population of 3.5 million people. RESULTS We identified 114,168 admissions with a primary (first-listed) ID diagnosis and 220,483 admissions with any-listed ID diagnosis, accounting for 8.9 % [95 % confidence interval (CI) 8.9-9.0 %] and 17.2 % (95 % CI 17.1-17.3) of all 1,284,559 admissions, respectively. Annually, 439,837 bed-days (range 413,707-488,520) were occupied by patients with an ID diagnosis, utilizing 22.8 % of total bed capacity. The median length of stay for patients with primary ID diagnosis and secondary ID diagnosis was 6 days (IQR 3-11) and 10 days (IQR 5-19), respectively. The most common diagnosis across all age groups was "pneumonia" (22.8 and 16.2 % of ID admissions as primary and secondary diagnosis, respectively). In-hospital mortality was 6.8 % (95 % CI 6.6-6.9) and 8.9 % (95 % CI 8.7-9.1) for ID as primary and secondary diagnosis, respectively. CONCLUSION Infectious diseases contribute significantly to the overall burden of disease in a health system caring for an urban German population. In view of the magnitude of ID's contribution, establishing more specialists in ID medicine and adjusting the reimbursements for managing infection-related admissions should be made a public health priority in Germany.
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Tong SYC, Davis JS, Eichenberger E, Holland TL, Fowler VG. Staphylococcus aureus infections: epidemiology, pathophysiology, clinical manifestations, and management. Clin Microbiol Rev 2015; 28:603-61. [PMID: 26016486 PMCID: PMC4451395 DOI: 10.1128/cmr.00134-14] [Citation(s) in RCA: 2785] [Impact Index Per Article: 309.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Staphylococcus aureus is a major human pathogen that causes a wide range of clinical infections. It is a leading cause of bacteremia and infective endocarditis as well as osteoarticular, skin and soft tissue, pleuropulmonary, and device-related infections. This review comprehensively covers the epidemiology, pathophysiology, clinical manifestations, and management of each of these clinical entities. The past 2 decades have witnessed two clear shifts in the epidemiology of S. aureus infections: first, a growing number of health care-associated infections, particularly seen in infective endocarditis and prosthetic device infections, and second, an epidemic of community-associated skin and soft tissue infections driven by strains with certain virulence factors and resistance to β-lactam antibiotics. In reviewing the literature to support management strategies for these clinical manifestations, we also highlight the paucity of high-quality evidence for many key clinical questions.
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Affiliation(s)
- Steven Y C Tong
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Joshua S Davis
- Global and Tropical Health, Menzies School of Health Research, Darwin, Northern Territory, Australia
| | - Emily Eichenberger
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Thomas L Holland
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina, USA
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Bai AD, Showler A, Burry L, Steinberg M, Ricciuto DR, Fernandes T, Chiu A, Raybardhan S, Science M, Fernando E, Tomlinson G, Bell CM, Morris AM. Impact of Infectious Disease Consultation on Quality of Care, Mortality, and Length of Stay in Staphylococcus aureus Bacteremia: Results From a Large Multicenter Cohort Study. Clin Infect Dis 2015; 60:1451-61. [DOI: 10.1093/cid/civ120] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2014] [Accepted: 02/03/2015] [Indexed: 11/14/2022] Open
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Bergin SP, Holland TL, Fowler VG, Tong SYC. Bacteremia, Sepsis, and Infective Endocarditis Associated with Staphylococcus aureus. Curr Top Microbiol Immunol 2015; 409:263-296. [PMID: 26659121 DOI: 10.1007/82_2015_5001] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Bacteremia and infective endocarditis (IE) are important causes of morbidity and mortality associated with Staphylococcus aureus infections. Increasing exposure to healthcare, invasive procedures, and prosthetic implants has been associated with a rising incidence of S. aureus bacteremia (SAB) and IE since the late twentieth century. S. aureus is now the most common cause of bacteremia and IE in industrialized nations worldwide and is associated with excess mortality when compared to other pathogens. Central tenets of management include identification of complicated bacteremia, eradicating foci of infection, and, for many, prolonged antimicrobial therapy. Evolving multidrug resistance and limited therapeutic options highlight the many unanswered clinical questions and urgent need for further high-quality clinical research.
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Timsit JF, Soubirou JF, Voiriot G, Chemam S, Neuville M, Mourvillier B, Sonneville R, Mariotte E, Bouadma L, Wolff M. Treatment of bloodstream infections in ICUs. BMC Infect Dis 2014; 14:489. [PMID: 25431091 PMCID: PMC4289315 DOI: 10.1186/1471-2334-14-489] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 09/03/2014] [Indexed: 11/24/2022] Open
Abstract
Bloodstream infections (BSIs) are frequent in ICU and is a prognostic factor of severe sepsis. Community acquired BSIs usually due to susceptible bacteria should be clearly differentiated from healthcare associated BSIs frequently due to resistant hospital strains. Early adequate treatment is key and should use guidelines and direct examination of samples performed from the infectious source. Previous antibiotic therapy knowledge, history of multi-drug resistant organism (MDRO) carriage are other major determinants of first choice antimicrobials in heathcare-associated and nosocomial BSIs. Initial antimicrobial dose should be adapted to pharmacokinetic knowledge. In general, a high dose is recommended at the beginning of treatment. If MDRO is suspected combination antibiotic therapy is mandatory because it increase the spectrum of treatment. Most of time, combination should be pursued no more than 2 to 5 days. Given the negative impact of useless antimicrobials, maximal effort should be done to decrease the antibiotic selection pressure. De-escalation from a broad spectrum to a narrow spectrum antimicrobial decreases the antibiotic selection pressure without negative impact on mortality. Duration of therapy should be shortened as often as possible especially when organism is susceptible, when the infection source has been totally controlled.
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Abstract
IMPORTANCE Several management strategies may improve outcomes in patients with Staphylococcus aureus bacteremia. OBJECTIVES To review evidence of management strategies for S. aureus bacteremia to determine whether transesophageal echocardiography is necessary in all adult cases and what is the optimal antibiotic therapy for methicillin-resistant S. aureus (MRSA) bacteremia. EVIDENCE REVIEW A PubMed search from inception through May 2014 was performed to identify studies addressing the role of transesophageal echocardiography in S. aureus bacteremia. A second search of PubMed, EMBASE, and the Cochrane Library from January 1990 through May 2014 was performed to find studies addressing antibiotic treatment for MRSA bacteremia. Studies reporting outcomes from antibiotic therapy for MRSA bacteremia were included. All searches, which were limited to English and focused on adults, were augmented by review of bibliographic references from included studies. The quality of evidence was assessed using the Grades of Recommendation, Assessment, Development and Evaluation system with consensus of independent evaluations by at least 2 of the authors. FINDINGS In 9 studies with a total of 4050 patients, use of transesophageal echocardiography was associated with higher rates of a diagnosis of endocarditis (14%-28%) compared with transthoracic echocardiography (2%-15%). In 4 studies, clinical or transthoracic echocardiography findings did not predict subsequent transesophageal echocardiography findings of endocarditis. Five studies identified clinical or transthoracic echocardiography characteristics associated with low risk of endocarditis (negative predictive values from 93% to 100%). Characteristics associated with a low risk of endocarditis include absence of a permanent intracardiac device, sterile follow-up blood cultures within 4 days after the initial set, no hemodialysis dependence, nosocomial acquisition of S. aureus bacteremia, absence of secondary foci of infection, and no clinical signs of infective endocarditis. Of 81 studies of antibiotic therapy for MRSA bacteremia, only 1 high-quality trial was identified. In that study of 246 patients with S. aureus bacteremia, daptomycin was not inferior to vancomycin or an antistaphylococcal penicillin, each in combination with low-dose, short-course gentamicin (clinical success rate, 44.2% [53/120] vs 41.7% [48/115]; absolute difference, 2.4% [95% CI, -10.2% to 15.1%]). CONCLUSIONS AND RELEVANCE All adult patients with S. aureus bacteremia should undergo echocardiography. Characteristics of low-risk patients with S. aureus bacteremia for whom transesophageal echocardiography can be safely avoided have been identified. Vancomycin and daptomycin are the first-line antibiotic choices for MRSA bacteremia. Well-designed studies to address the management of S. aureus bacteremia are needed.
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Affiliation(s)
- Thomas L. Holland
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Christopher Arnold
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
| | - Vance G. Fowler
- Division of Infectious Diseases & International Health, Department of Medicine, Duke University School of Medicine, Durham, NC 27710, USA
- Duke Clinical Research Institute, Duke University, Durham, NC
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37
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Lopez-Cortes LE, Rodriguez-Bano J. Reply to Fries et al and Valentin et al. Clin Infect Dis 2014; 58:600-1. [DOI: 10.1093/cid/cit732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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