Early-Outcome Differences between Acute and Chronic Periprosthetic Joint Infections-A Retrospective Single-Center Study

Periprosthetic joint infections (PJI) are serious complications after arthroplasty, associated with high morbidity, mortality, and complex treatment processes. The outcomes of different PJI entities are largely unknown. The aim of this study was to access the early outcomes of different PJI entities. A retrospective, single-center study was conducted. The characteristics and outcomes of patients with PJI treated between 2018 and 2019 were evaluated 12 months after the completion of treatment. Primary endpoints were mortality, relapse free survival (RFS) and postoperative complications (kidney failure, sepsis, admission to ICU). A total of 115 cases were included [19.1% early (EI), 33.0% acute late (ALI), and 47.8% chronic infections (CI)]. Patients with ALI were older (p = 0.023), had higher ASA scores (p = 0.031), preoperative CRP concentrations (p = 0.011), incidence of kidney failure (p = 0.002) and sepsis (p = 0.026). They also tended towards higher in-house mortality (ALI 21.1%, 13.6% EI, 5.5% CI) and admission to ICU (ALI 50.0%, 22.7% EI, 30.9% CI). At 12 months, 15.4% of patients with EI had a relapse, compared to 38.1% in ALI and 36.4% in CI. There are differences in patient characteristics and early outcomes between PJI entities. Patients with EI have better early clinical outcomes. Patients with ALI require special attention during follow-up because they have higher occurrences of relapses and postoperative complications than patients with EI and CI.

Changes in antibiotic consumption, AMR and Clostridioides difficile infections in a large tertiary-care center following the implementation of institution-specific guidelines for antimicrobial therapy: A nine-year interrupted time series study

BACKGROUND

Institution-specific guidelines (ISGs) within the framework of antimicrobial stewardship programs offer locally tailored decision support taking into account local pathogen and resistance epidemiology as well as national and international guidelines.

OBJECTIVES

To assess the impact of ISGs for antimicrobial therapy on antibiotic consumption and subsequent changes in resistance rates and Clostridioides difficile infections (CDIs).

METHODS

The study was conducted at the Leipzig University Hospital, a 1,451-bed tertiary-care medical center, and covered the years 2012 to 2020. Since 2014, ISGs were provided to optimize empirical therapies, appropriate diagnostics, and antimicrobial prophylaxis. We used interrupted time series analysis (ITSA) and simple linear regression to analyze changes in antimicrobial consumption, resistance and CDIs.

RESULTS

Over the study period, 1,672,200 defined daily doses (DDD) of antibiotics were dispensed, and 85,645 bacterial isolates as well as 2,576 positive C. difficile cultures were collected. Total antimicrobial consumption decreased by 14% from 2012 to 2020, without clear impact of the deployment of ISGs. However, implementation of ISGs was associated with significant decreases in the use of substances that were rarely recommended (e.g., fluoroquinolones). Over the whole study period, we observed declining resistance rates to most antibiotic classes of up to 25% in Enterobacterales, staphylococci, and Pseudomonas aeruginosa. Switching from ceftriaxone to cefotaxime was associated with reduced resistance to third-generation cephalosporins. The number of CDI cases fell by 65%, from 501 in 2012 to 174 in 2020.

CONCLUSIONS

Well-implemented ISGs can have a significant, immediate, and lasting impact on the prescription behavior. ISGs might thereby contribute to reduce resistance rates and CDI incidences in the hospital setting.

[Antibiotics Stewardship Team Recommendations - An Analysis under Routine Conditions in a University Hospital]

AIM

To evaluate recommendations of an antibiotic stewardship (ABS) team during routine weekly visits and to analyse their implementation and reasons for non-implementation by the ward physicians.

METHODS

Multiprofessional ABS Rounds (members: infectiology, microbiology, pharmacy and hospital epidemiology) were accompanied by an observer in nine intensive and peripheral wards of a university hospital (1451 beds) for eight weeks. The recommendations of the ABS team were prospectively analysed, and when these were not implemented, ward physicians in charge were asked to give reasons for non-implementation.

RESULTS

A total of 262 patients were visited in the course of 359 ABS visits. A median of four physicians and one pharmacist (Q25/Q75: 4/6) participated in the ABS rounds. In 177/359 (49%) of visits, at least one recommendation for anti-infective therapy was given; the total number of recommendations made was 210. The most frequent (38%, 80/210) recommendations were related to the prescribed therapy duration. The more different the professional groups participating in the ABS rounds, the larger was the number of recommendations given (p=0.016; odds ratio=1.018 (1.003-1.033)). 62/210 (30%) of the ABS recommendations were not implemented by the ward physicians in charge. The most frequent reason (32%: 20/62) for this was the deliberate decision by the physicians to deviate from the recommended therapy.

CONCLUSIONS

The high recommendation rate of 50% demonstrates the need for optimizing therapy by the ABS teams in routine practice. The larger the number of different specialists participating in single visits, the larger was the number of recommendations. Reasons for the lack of implementations need to be critically examined by both the ABS team and the ward physicians in charge.

Assessing the impact of institution-specific guidelines for antimicrobials on doctors' prescribing behavior at a German tertiary-care center and the additional benefits of providing a mobile application

Objective

To assess usage patterns, perceived usability, and effects of institution-specific guidelines (ISGs) for antimicrobials on clinicians’ prescribing behavior and the additional benefits of the mobile application (app), a single-center survey among medical doctors was performed.

Methods

The study was carried out in a 1451-bed tertiary-care academic medical center in Leipzig, Germany. To ensure optimal empirical antibiotic therapies, appropriate diagnostics, and targeted antimicrobial prophylaxis, ISGs were provided as printed pocket guides (since 2014), a PDF version on ward computers, and a mobile app (since 2017). For the survey, we used an electronically structured cross-sectional questionnaire with 31 items, ordinal Likert scales, and percent bars, allowing for quantitative comparisons.

Results

Of the 914 doctors contacted by email, 282 (31%) responded, and 254 (28%) surveys were eligible. ISGs were reported to be the most commonly used source of information for antimicrobial prescribing among the respondents. Ninety-four percent used ISGs at least once and 55% at least weekly. On average, participants reported using them in 38% of antibiotic prescriptions and to adhere to consulted recommendations in 87% of cases. Young clinicians (≤ 30 years) reported significantly higher use of the ISGs than their older colleagues (47% vs. 35% of antibiotic prescriptions, p = 0.004). Ninety-six percent of users found ISGs to be user-friendly, and nearly 100% recommended ISGs to other colleagues. Forty-five percent regarded the app as the most user-friendly way to access ISGs, and app users were significantly more likely to use ISGs regularly (p = 0.024). Eighty-four percent reported behavioral changes regarding at least one aspect of antimicrobial therapy (e.g. duration, application mode, prescription frequency), while 54% reported changes regarding the choice of specific substance groups.

Conclusions

ISGs are used regularly and appear to have a relevant impact on clinicians’ prescribing habits. A mobile app may be the most effective way to provide ISGs, although multiple platforms seem to add value. While the majority of participants reported perceived effects on their prescribing behavior, this study does not allow any conclusions to be drawn about the extent of the effects of ISGs on antibiotic use and patient outcomes.

Switching From Ceftriaxone to Cefotaxime Significantly Contributes to Reducing the Burden of Clostridioides difficile infections

We analyzed Clostridioides difficile infection (CDI) rates and various antimicrobials' application densities from 2013 to 2019 at Leipzig University Hospital, Germany, by using multivariate linear regression. Ceftriaxone application was the only independent predictor of CDI incidence. Thus, antibiotics' specific pharmacokinetic and pharmacodynamic properties such as biliary excretion of ceftriaxone in its active form should be considered when determining their potential to cause CDI.

[Antibiotic stewardship (ABS). Part 1: Basics]

Against the background of increasing antimicrobial resistance, antibiotic stewardship (ABS) is an important measure to counteract the spread of resistant pathogens and multidrug resistance. For Germany and Austria, a comprehensive S3 guideline is available, which was last updated in 2018. The control of antibiotic or anti-infective use in hospitals should be guided by specialized ABS teams. At the hospital level, ABS also includes a structured ongoing analysis of local antibiotic use and resistance data. Recommendations for locally adapted therapy regimens should be derived and implemented from this data analysis. ABS consists of regular ward rounds ("ABS visits"), during which members of the ABS team review the indication, dosage, route of administration and duration of antimicrobial therapy at the bedside. Here, the key challenge is to save antibiotics without compromising the individual patient. Digitalization and artificial intelligence offer new options for ABS, while the adaption of inpatient concepts to outpatient care is also important.

[Antibiotic stewardship (ABS). Part 2: Application]

Antibiotic stewardship (ABS) is an important measure to counteract the spread of resistant pathogens and multidrug resistance. The most important ABS tools include the implementation of local guidelines, the development of a house-related list of anti-infective agents, regular ABS visits and practice-oriented internal training events. Effective strategies for therapy optimization include indication testing and therapy evaluation, dose optimization as well as determining an appropriate duration of therapy. Oralization of anti-infectives (sequence therapy) should be supported by consistent clinical criteria in in-house guidelines. The incidence of Clostridioides difficile infections (CDI) can be more than halved by restricting the so-called "4C antibiotics". Point-of-care tests help to minimize the use of antibiotics in the outpatient setting. Vaccination reduces the need for antibiotic therapy.

N1-Hetaryl substituted pyridine- and pyrazinecarboxamidrazones with antimycobacterial activity

A series of amidrazones was prepared and characterized by 1H NMR and mass spectroscopy. The substances were tested against M. tuberculosis, M. avium, M. intracellulare, and M. lufu. Compounds 11-13 exhibit a satisfactory inhibition of mycobacteria.