The pattern and impact of infectious diseases consultation on antimicrobial prescription

Do infectious disease consultations improve outcomes of surgical management of MRONJ?

OBJECTIVES

The aim of this study is to evaluate the effect of infectious disease (ID) consultations on outcomes of patients with surgically managed medication-related osteonecrosis of the jaw (MRONJ).

STUDY DESIGN

We utilized a retrospective cohort study of patients managed surgically for MRONJ at an academic center. The primary predictor was presence vs absence of ID consult. The primary outcome was the surgical outcome, and the secondary outcomes were length of hospital stay and continuous postoperative antibiotic duration in days. Descriptive and multivariate statistics were computed.

RESULTS

The study included 146 surgically managed patients with MRONJ (mean age = 68.7 years), with 101 women (69%). Rates of improvement in MRONJ were similar among both groups (no ID consult = 86.0% and ID consult = 80.4%, P = .39). ID consult was associated with a greater length of hospital stay (ID consult = 3.17 days [1.95-4.40 days]) vs no consult = 1.25 days [0.895-1.61 days], P < .05) and longer duration of postoperative antibiotics (ID consult = 51.4 days [37.1-65.8 days] vs no consult = 26.1 days [22.3-29.9 days], P < .05).

CONCLUSIONS

The outcomes of surgically managed MRONJ did not differ between patients who had ID consultations vs those who did not. In a subset of patients with a complex disease course based on the clinical and microbiologic findings, ID consultations may be beneficial.

Bacteremia in the Gulf Cooperation Council Region: A Review of the Literature 2013-2023

Bloodstream infections (BSIs) are amongst the leading healthcare-associated infections (HCAIs), and their comprehensive evaluation and management are of global and regional importance. This narrative review examines and reports data on BSIs from the Gulf Cooperation Council (GCC) region covering the period between 2013 and 2023. The reviewed literature demonstrated that BSIs were frequently associated with critical care settings such as the Intensive Care Unit (ICU) and were often associated with invasive lines and devices [such as central-line associated BSI (CLABSI)]. Fever was the main presenting symptom, while diabetes mellitus and hypertension were the common associated comorbidities. High mortality rates were reported for BSIs, particularly when caused by multidrug-resistant (MDR) Gram-negative pathogens. There was a wide range of antimicrobial resistance rates reported across the region; however, carbapenem-resistance rates exceeding 30% were reported for Pseudomonas aeruginosa, Acinetobacter baumannii and Klebsiella pneumoniae. Few publications included molecular mechanisms of carbapenem resistance; however, when mechanisms were reported they were dominated by OXA-48. In conclusion, the lack of structured surveillance programs and networks to monitor microbiological phenotypic and genotypic patterns as well as clinical outcomes across the region means there is paucity of uniform data on BSIs across the GCC region. To bridge this gap, we recommend timely surveillance programs for the monitoring of resistance and outcomes.

Association Between Infectious Diseases Consultation and Mortality in Hospitalized Patients With Gram-negative Bloodstream Infection: A Retrospective Population-wide Cohort Study

OBJECTIVES

Data supporting routine infectious diseases (ID) consultation in gram-negative bloodstream infection (GN-BSI) are limited. We evaluated the association between ID consultation and mortality in patients with GN-BSI in a retrospective population-wide cohort study in Ontario using linked health administrative databases.

METHODS

Hospitalized adult patients with GN-BSI between April 2017 and December 2021 were included. The primary outcome was time to all-cause mortality censored at 30 days, analyzed using a mixed effects Cox proportional hazards model with hospital as a random effect. ID consultation 1-10 days after the first positive blood culture was treated as a time-varying exposure.

RESULTS

Of 30 159 patients with GN-BSI across 53 hospitals, 11 013 (36.5%) received ID consultation. Median prevalence of ID consultation for patients with GN-BSI across hospitals was 35.0% with wide variability (range 2.7%-76.1%, interquartile range 19.6%-41.1%). In total, 1041 (9.5%) patients who received ID consultation died within 30 days, compared to 1797 (9.4%) patients without ID consultation. In the fully adjusted multivariable model, ID consultation was associated with mortality benefit (adjusted hazard ratio [HR] 0.82, 95% confidence interval [CI] .77-.88, P < .0001; translating to absolute risk reduction of -3.8% or number needed to treat [NNT] of 27). Exploratory subgroup analyses of the primary outcome showed that ID consultation could have greater benefit in patients with high-risk features (nosocomial infection, polymicrobial or non-Enterobacterales infection, antimicrobial resistance, or non-urinary tract source).

CONCLUSIONS

Early ID consultation was associated with reduced mortality in patients with GN-BSI. If resources permit, routine ID consultation for this patient population should be considered to improve patient outcomes.

Pharmacotherapies for multidrug-resistant gram-positive infections: current options and beyond

INTRODUCTION

Infections due to multidrug-resistant organisms (MDRO) are a serious concern for public health with high morbidity and mortality. Though many antibiotics have been introduced to manage these infections, there are remaining concerns regarding the optimal management of Gram-positive MDROs.

AREAS COVERED

A literature search on the PubMed/Medline database was conducted. We applied no language and time limits for the search strategy. In this narrative review, we discuss the current options for managing Gram-positive MDROs as well as non-traditional antibacterial agents in development.

EXPERT OPINION

Despite their introduction more than 70 years ago, glycopeptides are still the cornerstone in treating Gram-positive infections: all registrative studies of new antibiotics have glycopeptides as control; these studies are designed as not inferior studies, therefore it is almost impossible to give recommendations other than the use of glycopeptides in the treatment of Gram-positive infections. The best evidence on treatments different from glycopeptides comes from post-hoc analysis and meta-analysis. Non-traditional antibacterial agents are being studied to aid in short and effective antibiotic therapies. The use of non-traditional antibacterial agents is not restricted to replacing traditional antibacterial agents with alternative therapies; instead, they should be used in combination with antibiotic therapies.

Home Monitoring for Fever: An Inexpensive Screening Method to Prevent Household Spread of COVID-19

The COVID-19 pandemic surge has exceeded testing capacities in many parts of the world. We investigated the effectiveness of home temperature monitoring for early identification of COVID-19 patients.

Study Design –

We compared home temperature measurements from a convenience sample of 1180 individuals who reported being test positive for SARS-CoV-2 to an age, sex, and location matched control group of 1249 individuals who had not tested positive.

Methods –

All individuals monitored their temperature at home using an electronic smartphone thermometer that relayed temperature measurements and symptoms to a centralized cloud based, de-identified data bank.

Results -

Individuals varied in the number of times they monitored their temperature. When temperature was monitored for over 72 hours fever (≥ 37.6°C or 99.7°F or a change in temperature of ≥ 1°C or 1.8°F) was detected in 73% of test positive individuals, a sensitivity comparable to rapid SARS-CoV-2 antigen tests. When compared to our control group the specificity of fever for COVID-19 was 0.70. However, when fever was combined with complaints of loss of taste and smell, difficulty breathing, fatigue, chills, diarrhea, or stuffy nose the odds ratio of having COVID-19 was sufficiently high as to obviate the need to employ RTPCR or antigen testing to screen for and isolate coronavirus infected cases.

Conclusions -

Our findings suggest that home temperature monitoring could serve as an inexpensive convenient screen for the onset of COVID-19, encourage earlier isolation of potentially infected individuals, and more effectively reduce the spread of infection in closed spaces.

The role of infectious disease consultations in the management of patients with fever in a long-term care facility

BACKGROUND

Infectious disease (ID) clinicians can provide essential services for febrile patients in tertiary hospitals. The aim of this study was to evaluate the role of ID consultations (IDC) in managing hospitalized patients with infections in an oriental medical hospital (OMH), which serves as a long-term care facility. To our knowledge, this is the first study on the role of IDCs in managing patients in an OMH.

METHODS

This retrospective study was conducted in an OMH in Seoul, Korea, from June 2006 to June 2013.

RESULTS

Among the 465 cases of hospital-acquired fever, 141 (30.3%) were referred for ID. The most common cause of fever was infection in both groups. The peak body temperature of the patient was higher in IDC group (38.8±0.6°C vs. 38.6±0.5°C, p<0.001). Crude mortality at 30 days (14.6% vs. 7.8%, p = 0.043) and infection-attributable mortality (15.3% vs. 6.7%, p = 0.039) were higher in the No-IDC group. Multivariable analysis showed that infection as the focus of fever (adjusted Odd ratio [aOR] 3.49, 95% confidence interval (CI) 1.64-7.44), underlying cancer (aOR 10.32, 95% CI 4.34-24.51,), and multiorgan dysfunction syndrome (aOR 15.68, 95% CI 2.06-119.08) were associated with increased 30-day mortality. Multivariate analysis showed that in patients with infectious fever, appropriate antibiotic therapy (aOR 0.19, 95% CI 0.05-0.76) was the only factor associated with decreased infection-attributable mortality while underlying cancer (aOR 7.80, 95% CI 2.555-23.807) and severe sepsis or septic shock at the onset of fever (aOR 10.15, 95% CI 1.00-102.85) were associated with increased infection-attributable mortality.

CONCLUSION

Infection was the most common cause of fever in patients hospitalized for OMH. Infection as the focus of fever, underlying cancer, and MODS was associated with increased 30-day mortality in patients with nosocomial fever. Appropriate antibiotic therapy was associated with decreased infection-attributable mortality in patients with infectious fever.

Association of Infectious Disease Physician Approval of Peripherally Inserted Central Catheter With Appropriateness and Complications

IMPORTANCE

Peripherally inserted central catheters (PICCs) are frequently used to deliver intravenous antimicrobial therapy. However, inappropriate PICC use may lead to patient harm.

OBJECTIVE

To evaluate whether infectious disease physician approval prior to PICC placement for intravenous antimicrobials is associated with more appropriate device use and fewer complications.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study of 21 653 PICCs placed for a primary indication of intravenous antimicrobial therapy between January 1, 2015, and July 26, 2019, was conducted in 42 hospitals participating in a quality collaborative across Michigan among hospitalized medical patients.

MAIN OUTCOMES AND MEASURES

Appropriateness of PICCs was defined according to the Michigan Appropriateness Guide for Intravenous Catheters as a composite measure of (1) single-lumen catheter use, (2) avoiding use of PICCs for 5 days or less, and (3) avoiding use of PICCs for patients with chronic kidney disease (defined as an estimated glomerular filtration rate <45 mL/min/1.73 m2). Complications related to PICCs included catheter occlusion, deep vein thrombosis, and central line-associated bloodstream infection. The association between infectious disease physician approval, device appropriateness, and catheter complications was assessed using multivariable models, adjusted for patient comorbidities and hospital clustering. Results were expressed as odds ratios with 95% CIs.

RESULTS

A total of 21 653 PICCs were placed for intravenous antimicrobials (11 960 PICCs were placed in men [55.2%]; median age, 64.5 years [interquartile range, 53.4-75.4 years]); 10 238 PICCs (47.3%) were approved by an infectious disease physician prior to placement. Compared with PICCs with no documented approval, PICCs with approval by an infectious disease physician were more likely to be appropriately used (72.7% [7446 of 10 238] appropriate with approval vs 45.4% [5180 of 11 415] appropriate without approval; odds ratio, 3.53; 95% CI, 3.29-3.79; P < .001). Furthermore, approval was associated with lower odds of a PICC-related complication (6.5% [665 of 10 238] with approval vs 11.3% [1292 of 11 415] without approval; odds ratio, 0.55; 95% CI, 0.50-0.61).

CONCLUSIONS AND RELEVANCE

This cohort study suggests that, when PICCs were placed for intravenous antimicrobial therapy, infectious disease physician approval of PICC insertion was associated with more appropriate device use and fewer complications. Policies aimed at ensuring infectious disease physician approval prior to PICC placement for antimicrobials may improve patient safety.

Mapping hospital antimicrobial stewardship programmes in the Gulf Cooperation Council states against international standards: a systematic review

BACKGROUND

While there is evidence of implementation of antimicrobial stewardship programmes (ASPs) in the Gulf Cooperation Council (GCC) states, there has been limited benchmarking and mapping to international standards and frameworks.

AIM

To critically appraise and synthesize the evidence of ASP implementation in GCC hospitals with reference to the framework of the Centers for Disease Control and Prevention (CDC), identifying key facilitators and barriers.

METHODS

A systematic review protocol was developed based on Preferred Reporting Items for Systematic Reviews and Meta-analyses for Protocols guidelines. Five electronic databases were searched for studies published in English from 2010 onwards. Study selection, quality assessment and data extraction were performed independently by two reviewers. A narrative synthesis was conducted with ASP interventions mapped to CDC core elements.

FINDINGS

Seventeen studies were identified, most of which (N=11) were from Saudi Arabia. Mapping to the CDC framework identified key areas of strengths and weaknesses in reporting implementation. Studies more commonly reported core elements of pharmacy expertise, selected aspects of implementation actions, tracking, antibiotic use and resistance, and education. Little emphasis was placed on the reporting of leadership and accountability. Key implementation facilitators were physician and organization support, information systems and education, and barriers were dedicated staff, workload and funding.

CONCLUSION

There is a need to enhance the reporting of ASP implementation in GCC hospitals. The CDC framework should be used as a guide during the development, implementation and reporting of ASP interventions. Action is required to identify facilitators and overcome barriers, where possible.

Factors associated with treatment failure after advice from infectious disease specialists

OBJECTIVE

Risk factors associated with treatment failure after the infectious disease specialist's (IDS) advice remain unknown. We aimed to identify these risk factors.

METHODS

We included patients hospitalized in our tertiary care center who consulted an infectious disease specialist between January 2013 and April 2015. Treatment failure was defined by a composite criterion: signs of sepsis beyond Day 3, ICU admission, or death. Treatment success was defined by the patient's sustained clinical improvement.

RESULTS

A total of 240 IDS recommendations were made. Diagnosis was changed for 64 patients (26.7%) and 50 patients experienced treatment failure after the IDS advice. In multivariate analysis, compliance with the IDS advice was associated with a higher rate of success (OR=0.09, 95%CI [0.01-0.67]). Variables associated with treatment failure in the multivariate analysis were Charlson comorbidity score at admission (OR=1.24, 95%CI [1.03-1.50]), a history of infection or colonization with multidrug-resistant bacteria (OR=8.27, 95%CI [1.37-49.80]), and deterioration of the patient's status three days after the IDS advice (OR=12.50, 95%CI [3.16-49.46]).

CONCLUSION

Reassessing IDS recommendations could be interesting for specific patients to further adapt and improve them.

Knowledge and Attitude of Physicians Toward Prescribing Antibiotics and the Risk of Resistance in Two Reference Hospitals

INTRODUCTION

Antibiotics are essential and abundantly prescribed in hospitals because of their effectiveness and lifesaving benefits. However, the unnecessary use of antibiotics has been observed in earlier studies, and it has persisted through recent years as a major issue since it is one of the leading causes of antibiotic resistance. The increase in antibiotic resistance nowadays is one of the most critical concerns in global public health around the world. The objective of this study was to evaluate the knowledge and perceptions related to antibiotic prescription among physicians at our medical centers.

METHOD

A cross-sectional survey of non-infectious diseases specialized physicians. The study was conducted during 2015 at two tertiary care centers in Riyadh, Saudi Arabia.

RESULT

Of the 107 returned questionnaires, 93 were complete and valuable. Most respondents (82%) perceived antibiotic resistance to be a critical problem globally, and 78% also think that it is a very important national problem. These attitudes did not differ across specialty or level of training. Widespread antibiotic use and inappropriate empirical choices were believed by 81% of the participants to be important general causes of resistance. Only half of respondents thought that antibiotic restriction is a useful intervention to decrease the antibiotic resistance. The physicians believed educational interventions are the most useful and effective way to improve prescription patterns and decrease antibiotic resistance. Complications due to infection with resistant organisms were acknowledged by almost all of the participants, with some differences in their estimations of how often it will occur.

CONCLUSION

Antimicrobial resistance, globally and nationally, is considered as a serious threat, and physicians in this survey acknowledged that. Among the most significant factors is antimicrobial misuse, either by overprescribing or providing inappropriate drugs with some ambivalence, as well as the importance of hand hygiene and antibiotic restrictions. By adhering to local guidelines, continuous education, and other practical interventions, the burden of resistance can be alleviated, as highlighted in this survey.

Methodology in improving antibiotic implementation policies

The basic requirements of antibiotic prescribing are components of methodology; knowledge, logical reasoning, and analysis. Antimicrobial drugs are valuable but limited resources, different from other drugs and they are among the most commonly prescribed drugs all over the world. They are the only drugs which do not intentionally affect the patient. They affect the pathogens which invade the host. The emergence and spread of antibiotic-resistant pathogens are accelerated by heavy antibiotic usage. The effective antimicrobial stewardship and infection control program have been shown to limit the emergence of antimicrobial-resistant bacteria. In this respect, education for antibiotic prescribing could be designed by going through the steps of scientific methodology. A defined leadership and a coordinated multidisciplinary approach are necessary for optimizing the indication, selection, dosing, route of administration, and duration of antimicrobial therapy. In scenarios, knowledge is also as important as experience for critical decision making as is designated. In this setting, the prevalence and resistance mechanisms of antimicrobials, and their interactions with other drugs need to be observed. In this respect, infectious disease service should play an important role in improving antimicrobial use by giving advice on the appropriate use of antimicrobial agents, and implementing evidence-based guidelines.