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Rhee C, Strich JR, Chiotos K, Classen DC, Cosgrove SE, Greeno R, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Terry A, Winslow DL, Yealy DM, Klompas M. Improving Sepsis Outcomes in the Era of Pay-for-Performance and Electronic Quality Measures: A Joint IDSA/ACEP/PIDS/SHEA/SHM/SIDP Position Paper. Clin Infect Dis 2024; 78:505-513. [PMID: 37831591 DOI: 10.1093/cid/ciad447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Indexed: 10/15/2023] Open
Abstract
The Centers for Medicare & Medicaid Services (CMS) introduced the Severe Sepsis/Septic Shock Management Bundle (SEP-1) as a pay-for-reporting measure in 2015 and is now planning to make it a pay-for-performance measure by incorporating it into the Hospital Value-Based Purchasing Program. This joint IDSA/ACEP/PIDS/SHEA/SHM/SIPD position paper highlights concerns with this change. Multiple studies indicate that SEP-1 implementation was associated with increased broad-spectrum antibiotic use, lactate measurements, and aggressive fluid resuscitation for patients with suspected sepsis but not with decreased mortality rates. Increased focus on SEP-1 risks further diverting attention and resources from more effective measures and comprehensive sepsis care. We recommend retiring SEP-1 rather than using it in a payment model and shifting instead to new sepsis metrics that focus on patient outcomes. CMS is developing a community-onset sepsis 30-day mortality electronic clinical quality measure (eCQM) that is an important step in this direction. The eCQM preliminarily identifies sepsis using systemic inflammatory response syndrome (SIRS) criteria, antibiotic administrations or diagnosis codes for infection or sepsis, and clinical indicators of acute organ dysfunction. We support the eCQM but recommend removing SIRS criteria and diagnosis codes to streamline implementation, decrease variability between hospitals, maintain vigilance for patients with sepsis but without SIRS, and avoid promoting antibiotic use in uninfected patients with SIRS. We further advocate for CMS to harmonize the eCQM with the Centers for Disease Control and Prevention's (CDC) Adult Sepsis Event surveillance metric to promote unity in federal measures, decrease reporting burden for hospitals, and facilitate shared prevention initiatives. These steps will result in a more robust measure that will encourage hospitals to pay more attention to the full breadth of sepsis care, stimulate new innovations in diagnosis and treatment, and ultimately bring us closer to our shared goal of improving outcomes for patients.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - David C Classen
- Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ron Greeno
- Society of Hospital Medicine, Philadelphia, Pennsylvania, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Aisha Terry
- Department of Emergency Medicine, George Washington University School of Medicine, Washington D.C., USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Donald M Yealy
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA
- Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Doub JB, Heil EL, Manson T. Adjuvant intra-articular vancomycin for recalcitrant Staphylococcal prosthetic joint infections of the knee. Eur J Orthop Surg Traumatol 2024; 34:1031-1036. [PMID: 37864658 DOI: 10.1007/s00590-023-03764-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
OBJECTIVE Chronic prosthetic joint infection patients who fail conventional two-stage revision surgery are an especially difficult to treat patient population. Consequently, the objective of this study was to investigate the safety and long-term effectiveness of adjuvant intra-articular vancomycin therapy in conjunction with two-stage revision knee arthroplasties for recalcitrant Staphylococcal prosthetic joint infections. METHODS This was an observational cohort study of twelve patients with recalcitrant Staphylococcal prosthetic joint infections of the knee which had failed previous revision surgeries. Each patient subsequently underwent two-stage revision with placement of Hickman catheters to deliver intra-articular vancomycin therapy. In addition, systemic antibiotic therapy was administered for 6 weeks, and long-term follow-up was evaluated then for 5 years. RESULTS Seventy-five percent of the cohort have had no recurrence of their infections at 5 years. Two patients formed fistulas requiring above the knee amputations, and three patients had acute kidney injury. All patients had maximum measurable serum vancomycin trough levels that ranged from 6.1 to 93.6 mcg/mL. CONCLUSION The aggressive protocol used in this cohort with repeat two-stage revision surgery, intra-articular vancomycin and systemic antibiotics was able to prevent recurrence of infection in most patients, but higher than expected rates of acute kidney injury were observed in this study. Therefore, while intra-articular vancomycin therapy may have some effectiveness in treating recalcitrant prosthetic joint infections, its ability to eradicate all bacterial niduses is unproven, and clinicians should be cognizant of potential adverse events that can occur with this therapy.
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Affiliation(s)
- James B Doub
- Division of Infectious Diseases, University of Maryland School of Medicine, 725 West Lombard Street, BaltimoreMaryland, MD, 21201, USA.
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, 21201, USA
| | - Theodore Manson
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, 21201, USA
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Heil EL. Put the Fluoroquinolone Down and No One Gets Hurt. Clin Infect Dis 2023:ciad750. [PMID: 38134307 DOI: 10.1093/cid/ciad750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/04/2023] [Indexed: 12/24/2023] Open
Affiliation(s)
- Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Heil EL, Kaur H, Atalla A, Basappa S, Mathew M, Seung H, Johnson JK, Schrank GM. Comparison of Adjuvant Clindamycin vs Linezolid for Severe Invasive Group A Streptococcus Skin and Soft Tissue Infections. Open Forum Infect Dis 2023; 10:ofad588. [PMID: 38149106 PMCID: PMC10750261 DOI: 10.1093/ofid/ofad588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023] Open
Abstract
Background Linezolid may be an option for severe group A Streptococcus (GAS) infections based on its potent in vitro activity and antitoxin effects, but clinical data supporting its use over clindamycin are limited. This study evaluated treatment outcomes in patients with severe GAS skin and soft tissue infections who received either linezolid or clindamycin. Methods This retrospective single-center cohort study examined patients with GAS isolated from blood and/or tissue cultures with invasive soft tissue infection or necrotizing fasciitis who underwent surgical debridement and received linezolid or clindamycin for at least 48 hours. The primary outcome was percentage change in Sequential Organ Failure Assessment (SOFA) score from baseline through 72 hours of hospitalization. Results After adjustment for time to first surgical intervention among patients with a baseline SOFA score >0 (n = 23 per group), there was no difference in reduction of SOFA score over the first 72 hours in patients receiving clindamycin vs linezolid. In the entire cohort (n = 26, clindamycin; n = 29, linezolid), there was no difference in inpatient mortality (2% vs 1%) or any secondary outcomes, including duration of vasopressor therapy, intensive care unit length of stay, and antibiotic-associated adverse drug events. Conclusions There was no difference in reduction of critical illness as measured by SOFA score between baseline and 72 hours among patients treated with clindamycin vs linezolid. Given its more favorable side effect profile, linezolid may be a viable option for the treatment of serious GAS infections and should be further studied.
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Affiliation(s)
- Emily L Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Harpreet Kaur
- Department of Medicine, Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony Atalla
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sapna Basappa
- Department of Pharmacy, University of Massachusetts Memorial Medical Center, Worcester, Massachusetts, USA
| | - Minu Mathew
- Department of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Hyunuk Seung
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Gregory M Schrank
- Department of Medicine, Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Bork JT, Heil EL. What Is Left to Tackle in Inpatient Antimicrobial Stewardship Practice and Research. Infect Dis Clin North Am 2023; 37:901-915. [PMID: 37586930 DOI: 10.1016/j.idc.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Despite widespread uptake of antimicrobial stewardship in acute care hospitals, there is ongoing need for innovation and optimization of ASPs. This article discusses current antimicrobial stewardship practice challenges and ways to improve current antimicrobial stewardship workflows. Additionally, we propose new workflows that further engage front line clinicians in optimizing their own antibiotic decision making.
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Affiliation(s)
- Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology in the Department of Medicine, University of Maryland, School of Medicine, 22 S Greene Street, Baltimore, MD 21201, USA
| | - Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland, School of Pharmacy, 20 N Pine Street, Baltimore, MD 21201, USA.
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O’Shea JG, Cholli P, Heil EL, Buchacz K. Considerations for long-acting antiretroviral therapy in older persons with HIV. AIDS 2023; 37:2271-2286. [PMID: 37965737 PMCID: PMC10993170 DOI: 10.1097/qad.0000000000003704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
People with HIV (PWH) can now enjoy longer, healthier lives due to safe and highly effective antiretroviral therapy (ART), and improved care and prevention strategies. New drug formulations such as long-acting injectables (LAI) may overcome some limitations and issues with oral antiretroviral therapy and strengthen medication adherence. However, challenges and questions remain regarding their use in aging populations. Here, we review unique considerations for LAI-ART for the treatment of HIV in older PWH, including benefits, risks, pharmacological considerations, implementation challenges, knowledge gaps, and identify factors that may facilitate uptake of LA-ART in this population.
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Affiliation(s)
- Jesse G. O’Shea
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Preetam Cholli
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Emily L. Heil
- Department of Practice, Sciences, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Kate Buchacz
- Division of HIV Prevention, Centers for Disease Control and Prevention, Atlanta, Georgia
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7
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Zou I, Abate D, Newman M, Heil EL, Leekha S, Claeys KC. Crossroads of Antimicrobial and Diagnostic Stewardship: Assessing Risks to Develop Clinical Decision Support to Combat Multidrug-Resistant Pseudomonas. Open Forum Infect Dis 2023; 10:ofad512. [PMID: 37901124 PMCID: PMC10603593 DOI: 10.1093/ofid/ofad512] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 10/10/2023] [Indexed: 10/31/2023] Open
Abstract
Background Early detection of multidrug-resistant Pseudomonas aeruginosa (MDRP) remains challenging. Existing risk prediction tools are difficult to translate to bedside application. The goal of this study was to develop a simple electronic medical record (EMR)-integrated tool for prediction of MDRP infection. Methods This was a mixed-methods study. We conducted a split-sample cohort study of adult critical care patients with P aeruginosa infections. Two previously published tools were validated using c-statistic. A subset of variables based on strength of association and ease of EMR extraction was selected for further evaluation. A simplified tool was developed using multivariable logistic regression. Both c-statistic and theoretical trade-off of over- versus underprescribing of broad-spectrum MDRP therapy were assessed in the validation cohort. A qualitative survey of frontline clinicians assessed understanding of risks for MDRP and potential usability of an EMR-integrated tool to predict MDRP. Results The 2 previous risk prediction tools demonstrated similar accuracy in the derivation cohort (c-statistic of 0.76 [95% confidence interval {CI}, .69-.83] and 0.73 [95% CI, .66-.8]). A simplified tool based on 4 variables demonstrated reasonable accuracy (c-statistic of 0.71 [95% CI, .57-.85]) without significant overprescribing in the validation cohort. The risk factors were prior MDRP infection, ≥4 antibiotics prior to culture, infection >3 days after admission, and dialysis. Fourteen clinicians completed the survey. An alert providing context regarding individual patient risk factors for MDRP was preferred. Conclusions These results can be used to develop a local EMR-integrated tool to improve timeliness of effective therapy in those at risk of MDRP infections.
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Affiliation(s)
- Iris Zou
- Department of Nursing, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Daniel Abate
- Department of Pharmacy, Baltimore Washington Medical Center, Baltimore, Maryland, USA
| | - Michelle Newman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Practice and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Practice and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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8
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Bland CM, Heil EL, Asbell A, Smith SE, Jones BM. Delabeling for the duration? β-Lactam prescribing in hospitalized patients after penicillin skin testing. J Allergy Clin Immunol Pract 2023; 11:3245-3247. [PMID: 37329955 DOI: 10.1016/j.jaip.2023.06.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Christopher M Bland
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Ga; Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Ga.
| | - Emily L Heil
- Department of Practice, Sciences, and Health-Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Md
| | - Ashley Asbell
- Department of Pharmacy, Trident Medical Center, North Charleston, SC
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, Ga
| | - Bruce M Jones
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Savannah, Ga; Department of Pharmacy, St. Joseph's/Candler Health System, Savannah, Ga
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9
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Heil EL, Justo JA, Bork JT. Improving the Efficiency of Antimicrobial Stewardship Action in Acute Care Facilities. Open Forum Infect Dis 2023; 10:ofad412. [PMID: 37674632 PMCID: PMC10478156 DOI: 10.1093/ofid/ofad412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 07/28/2023] [Indexed: 09/08/2023] Open
Abstract
Inpatient antimicrobial stewardship (AS) programs are quality improvement programs tasked with improving antibiotic practices by augmenting frontline providers' antibiotic prescription. Prospective audit and feedback (PAF) and preauthorization (PRA) are essential activities in the hospital that can be resource intensive for AS teams. Improving efficiency in AS activities is needed when there are limited resources or when programs are looking to expand tasks beyond PAF and PRA, such as broad education or guideline development. Guidance on the creation and maintenance of alerts for the purpose of PAF reviews, modifications of antibiotic restrictions for PRA polices, and overall initiative prioritization strategies are reviewed. In addition, daily prioritization tools, such as the tiered approach, scoring systems, and regression modeling, are available for stewards to prioritize their daily workflow. Using these tools and guidance, AS programs can be productive and impactful in the face of resource limitation or competing priorities in the hospital.
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Affiliation(s)
- Emily L Heil
- Department of Practice, Sciences and Health Outcomes Research, School of Pharmacy, University of Maryland, Baltimore, Maryland, USA
| | - Julie Ann Justo
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy, University of South Carolina, Columbia, South Carolina, USA
- Department of Pharmacy, Prisma Health Richland Hospital, Columbia, South Carolina, USA
| | - Jacqueline T Bork
- Division of Infectious Diseases, Institute of Human Virology, Department of Medicine, School of Medicine, University of Maryland, Baltimore, Maryland, USA
- Veterans Affairs (VA) Maryland Health Care System, Baltimore, Maryland, USA
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Mupeta F, Sivile S, Toeque MG, Fwoloshi S, Zulu PM, Chanda D, Mbewe N, Mwitumwa M, Chanda C, Kandiwo N, Ziko L, Mwansa T, Matibula P, Mugala A, Traver EC, Tripathi RK, Heil EL, Patel DM, Riedel DJ, Hachaambwa L, Mulenga L, Claassen CW. The UTH-UMB Global Health Education Collaboration: Building a Bidirectional Exchange Based on Equity and Reciprocity. Ann Glob Health 2023; 89:52. [PMID: 37575336 PMCID: PMC10418132 DOI: 10.5334/aogh.3718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 06/26/2023] [Indexed: 08/15/2023] Open
Abstract
The global health exchange program between the University Teaching Hospitals (UTH) of Lusaka, Zambia and the University of Maryland, Baltimore (UMB) has been operating since 2015. As trainees and facilitators of this exchange program, we describe our experiences working in Lusaka and Baltimore, and strengths and challenges of the partnership. Since 2015, we have facilitated rotations for 71 UMB trainees, who spent four weeks on the Infectious Disease (ID) team at UTH. Since 2019 with funding from UMB, nine UTH ID trainee physicians spent up to six weeks each rotating on various ID consult services at University of Maryland Medical Center (UMMC). Challenges in global health rotations can include inadequate preparation or inappropriate expectations among high-income country trainees, low-value experiences for low- and middle-income country trainees, lack of appropriate mentorship at sites, and power imbalances in research collaborations. We try to mitigate these issues by ensuring pre-departure and on-site orientation for UMB trainees, cross-cultural mentored experiences for all trainees, and intentional sharing of authorship and credit on scientific collaborations. We present a description of our medical education collaboration as a successful model for building equitable and reciprocal collaborations between low- and middle-income countries and high-income countries, and offer suggestions for future program initiatives to enhance global health education equity among participants and organizations.
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Affiliation(s)
- Francis Mupeta
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Suilanji Sivile
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Ministry of Health, Ndeke House, Lusaka, ZM
| | - Mona-Gekanju Toeque
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sombo Fwoloshi
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Paul Msanzya Zulu
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Duncan Chanda
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Nyuma Mbewe
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Department of Internal Medicine, Ndola Teaching Hospital, Ndola, ZM
| | - Mundia Mwitumwa
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Chitalu Chanda
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Zambia National Public Health Institute, Lusaka, ZM
| | - Nyakulira Kandiwo
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Luunga Ziko
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Tilele Mwansa
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Peter Matibula
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | - Anchidinka Mugala
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
| | | | | | - Emily L. Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Devang M. Patel
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - David J. Riedel
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lottie Hachaambwa
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Lloyd Mulenga
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Ministry of Health, Ndeke House, Lusaka, ZM
| | - Cassidy W. Claassen
- Division of Infectious Diseases, Department of Medicine, University of Zambia School of Medicine, Lusaka, ZM
- Adult Infectious Diseases Center, University Teaching Hospital, Lusaka, ZM
- Center for International Health, Education, and Biosecurity, University of Maryland School of Medicine, Baltimore, MD, USA
- University of Maryland School of Medicine, Baltimore, MD, USA
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Baghdadi JD, Goodman KE, Magder LS, Heil EL, Claeys K, Bork J, Harris AD. Clinical, contextual and hospital-level factors associated with escalation and de-escalation of empiric Gram-negative antibiotics among US inpatients. JAC Antimicrob Resist 2023; 5:dlad054. [PMID: 37193004 PMCID: PMC10182731 DOI: 10.1093/jacamr/dlad054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/19/2023] [Indexed: 05/18/2023] Open
Abstract
Background Empiric Gram-negative antibiotics are frequently changed in response to new information. To inform antibiotic stewardship, we sought to identify predictors of antibiotic changes using information knowable before microbiological test results. Methods We performed a retrospective cohort study. Survival-time models were used to evaluate clinical factors associated with antibiotic escalation and de-escalation (defined as an increase or decrease, respectively, in the spectrum or number of Gram-negative antibiotics within 5 days of initiation). Spectrum was categorized as narrow, broad, extended or protected. Tjur's D statistic was used to estimate the discriminatory power of groups of variables. Results In 2019, 2 751 969 patients received empiric Gram-negative antibiotics at 920 study hospitals. Antibiotic escalation occurred in 6.5%, and 49.2% underwent de-escalation; 8.8% were changed to an equivalent regimen. Escalation was more likely when empiric antibiotics were narrow-spectrum (HR 19.0 relative to protected; 95% CI: 17.9-20.1), broad-spectrum (HR 10.3; 95% CI: 9.78-10.9) or extended-spectrum (HR 3.49; 95% CI: 3.30-3.69). Patients with sepsis present on admission (HR 1.94; 95% CI: 1.91-1.96) and urinary tract infection present on admission (HR 1.36; 95% CI: 1.35-1.38) were more likely to undergo antibiotic escalation than patients without these syndromes. De-escalation was more likely with combination therapy (HR 2.62 per additional agent; 95% CI: 2.61-2.63) or narrow-spectrum empiric antibiotics (HR 1.67 relative to protected; 95% CI: 1.65-1.69). Choice of empiric regimen accounted for 51% and 74% of the explained variation in antibiotic escalation and de-escalation, respectively. Conclusions Empiric Gram-negative antibiotics are frequently de-escalated early in hospitalization, whereas escalation is infrequent. Changes are primarily driven by choice of empiric therapy and presence of infectious syndromes.
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Affiliation(s)
- Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kimberly Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Jacqueline Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, USA
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McAteer J, Lee JH, Cosgrove SE, Dzintars K, Fiawoo S, Heil EL, Kendall RE, Louie T, Malani AN, Nori P, Percival KM, Tamma PD. Defining the Optimal Duration of Therapy for Hospitalized Patients With Complicated Urinary Tract Infections and Associated Bacteremia. Clin Infect Dis 2023; 76:1604-1612. [PMID: 36633559 PMCID: PMC10411929 DOI: 10.1093/cid/ciad009] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2022] [Revised: 11/18/2022] [Accepted: 01/06/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Limited data are available to guide effective antibiotic durations for hospitalized patients with complicated urinary tract infections (cUTIs). METHODS We conducted an observational study of patients ≥18 years at 24 US hospitals to identify the optimal treatment duration for patients with cUTI. To increase the likelihood patients experienced true infection, eligibility was limited to those with associated bacteremia. Propensity scores were generated for an inverse probability of treatment weighted analysis. The primary outcome was recurrent infection with the same species ≤30 days of completing therapy. RESULTS 1099 patients met eligibility criteria and received 7 (n = 265), 10 (n = 382), or 14 (n = 452) days of therapy. There was no difference in the odds of recurrent infection for patients receiving 10 days and those receiving 14 days of therapy (aOR: .99; 95% CI: .52-1.87). Increased odds of recurrence was observed in patients receiving 7 days versus 14 days of treatment (aOR: 2.54; 95% CI: 1.40-4.60). When limiting the 7-day versus 14-day analysis to the 627 patients who remained on intravenous beta-lactam therapy or were transitioned to highly bioavailable oral agents, differences in outcomes no longer persisted (aOR: .76; 95% CI: .38-1.52). Of 76 patients with recurrent infections, 2 (11%), 2 (10%), and 10 (36%) in the 7-, 10-, and 14-day groups, respectively, had drug-resistant infections (P = .10). CONCLUSIONS Seven days of antibiotics appears effective for hospitalized patients with cUTI when antibiotics with comparable intravenous and oral bioavailability are administered; 10 days may be needed for all other patients.
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Affiliation(s)
- John McAteer
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jae Hyoung Lee
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathryn Dzintars
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Suiyini Fiawoo
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Practice, Science, and Health Outcomes Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Ronald E Kendall
- Department of Pharmacy, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
| | - Ted Louie
- Department of Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
| | - Anurag N Malani
- Department of Medicine, Trinity Health St. Joseph Mercy, Ann Arbor, Michigan, USA
| | - Priya Nori
- Department of Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kelly M Percival
- Department of Pharmaceutical Care, University of Iowa Hospitals & Clinics, Iowa City, Iowa, USA
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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13
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Heil EL, Claeys KC, Kline EG, Rogers TM, Squires KM, Iovleva A, Doi Y, Banoub M, Noval MM, Luethy PM, Shields RK. Early initiation of three-drug combinations for the treatment of carbapenem-resistant A. baumannii among COVID-19 patients. J Antimicrob Chemother 2023; 78:1034-1040. [PMID: 36869724 PMCID: PMC10319978 DOI: 10.1093/jac/dkad042] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES We evaluated the clinical characteristics and outcomes of patients with COVID-19 who received three-drug combination regimens for treatment of carbapenem-resistant Acinetobacter baumannii (CRAB) infections during a single-centre outbreak. Our objective was to describe the clinical outcomes and molecular characteristics and in vitro synergy of antibiotics against CRAB isolates. MATERIALS AND METHODS Patients with severe COVID-19 admitted between April and July 2020 with CRAB infections were retrospectively evaluated. Clinical success was defined as resolution of signs/symptoms of infection without need for additional antibiotics. Representative isolates underwent whole-genome sequencing (WGS) and in vitro synergy of two- or three-drug combinations was assessed by checkerboard and time-kill assays, respectively. RESULTS Eighteen patients with CRAB pneumonia or bacteraemia were included. Treatment regimens included high-dose ampicillin-sulbactam, meropenem, plus polymyxin B (SUL/MEM/PMB; 72%), SUL/PMB plus minocycline (MIN; 17%) or other combinations (12%). Clinical resolution was achieved in 50% of patients and 30-day mortality was 22% (4/18). Seven patients had recurrent infections, during which further antimicrobial resistance to SUL or PMB was not evident. PMB/SUL was the most active two-drug combination by checkerboard. Paired isolates collected before and after treatment with SUL/MEM/PMB did not demonstrate new gene mutations or differences in the activity of two- or three-drug combinations. CONCLUSIONS Use of three-drug regimens for severe CRAB infections among COVID-19 resulted in high rates of clinical response and low mortality relative to previous studies. The emergence of further antibiotic resistance was not detected phenotypically or through WGS analysis. Additional studies are needed to elucidate preferred antibiotic combinations linked to the molecular characteristics of infecting strains.
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Affiliation(s)
- Emily L Heil
- Department of Practice, Science, and Health Outcomes Research, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD, USA
| | - Kimberly C Claeys
- Department of Practice, Science, and Health Outcomes Research, University of Maryland School of Pharmacy, 20 North Pine Street, Baltimore, MD, USA
| | - Ellen G Kline
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tara M Rogers
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kevin M Squires
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Alina Iovleva
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Yohei Doi
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Mandee M Noval
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Ryan K Shields
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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14
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Liu K, Stern S, Heil EL, Li L, Khairi R, Heyward S, Wang H. Dexamethasone mitigates remdesivir-induced liver toxicity in human primary hepatocytes and COVID-19 patients. Hepatol Commun 2023; 7:e0034. [PMID: 36809346 PMCID: PMC9949788 DOI: 10.1097/hc9.0000000000000034] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is a global pandemic that has caused more than 600 million cases and over six million deaths worldwide. Despite the availability of vaccination, COVID-19 cases continue to grow making pharmacological interventions essential. Remdesivir (RDV) is an FDA-approved antiviral drug for treatment of both hospitalized and non-hospitalized COVID-19 patients, albeit with potential for hepatotoxicity. This study characterizes the hepatotoxicity of RDV and its interaction with dexamethasone (DEX), a corticosteroid often co-administered with RDV for inpatient treatment of COVID-19. METHODS Human primary hepatocytes and HepG2 cells were used as in vitro models for toxicity and drug-drug interaction studies. Real-world data from hospitalized COVID-19 patients were analyzed for drug-induced elevation of serum ALT and AST. RESULTS In cultured hepatocytes, RDV markedly reduced the hepatocyte viability and albumin synthesis, while it increased the cleavage of caspase-8 and caspase-3, phosphorylation of histone H2AX, and release of ALT and AST in a concentration-dependent manner. Importantly, co-treatment with DEX partially reversed RDV-induced cytotoxic responses in human hepatocytes. Moreover, data from COVID-19 patients treated with RDV with and without DEX co-treatment suggested that among 1037 patients matched by propensity score, receiving the drug combination was less likely to result in elevation of serum AST and ALT levels (≥ 3 × ULN) compared to the RDV alone treated patients (OR = 0.44, 95% CI = 0.22-0.92, p = 0.03). CONCLUSION Our findings obtained from in vitro cell-based experiments and patient data analysis provide evidence suggesting combination of DEX and RDV holds the potential to reduce the likelihood of RDV-induced liver injury in hospitalized COVID-19 patients.
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Affiliation(s)
- Kaiyan Liu
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sydney Stern
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Emily L. Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Linhao Li
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Rula Khairi
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Scott Heyward
- BioIVT, 1450 S Rolling Rd, Halethorpe, Maryland, USA
| | - Hongbing Wang
- Department of Pharmaceutical Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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15
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Goodman KE, Baghdadi JD, Magder LS, Heil EL, Sutherland M, Dillon R, Puzniak L, Tamma PD, Harris AD. Patterns, Predictors, and Intercenter Variability in Empiric Gram-Negative Antibiotic Use Across 928 United States Hospitals. Clin Infect Dis 2023; 76:e1224-e1235. [PMID: 35737945 PMCID: PMC9907550 DOI: 10.1093/cid/ciac504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/13/2022] [Accepted: 06/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Empiric antibiotic use among hospitalized adults in the United States (US) is largely undescribed. Identifying factors associated with broad-spectrum empiric therapy may inform antibiotic stewardship interventions and facilitate benchmarking. METHODS We performed a retrospective cohort study of adults discharged in 2019 from 928 hospitals in the Premier Healthcare Database. "Empiric" gram-negative antibiotics were defined by administration before day 3 of hospitalization. Multivariable logistic regression models with random effects by hospital were used to evaluate associations between patient and hospital characteristics and empiric receipt of broad-spectrum, compared to narrow-spectrum, gram-negative antibiotics. RESULTS Of 8 017 740 hospitalized adults, 2 928 657 (37%) received empiric gram-negative antibiotics. Among 1 781 306 who received broad-spectrum therapy, 30% did not have a common infectious syndrome present on admission (pneumonia, urinary tract infection, sepsis, or bacteremia), surgery, or an intensive care unit stay in the empiric window. Holding other factors constant, males were 22% more likely (adjusted odds ratio [aOR], 1.22 [95% confidence interval, 1.22-1.23]), and all non-White racial groups 6%-13% less likely (aOR range, 0.87-0.94), to receive broad-spectrum therapy. There were significant prescribing differences by region, with the highest adjusted odds of broad-spectrum therapy in the US West South Central division. Even after model adjustment, there remained substantial interhospital variability: Among patients receiving empiric therapy, the probability of receiving broad-spectrum antibiotics varied as much as 34+ percentage points due solely to the admitting hospital (95% interval of probabilities: 43%-77%). CONCLUSIONS Empiric gram-negative antibiotic use is highly variable across US regions, and there is high, unexplained interhospital variability. Sex and racial disparities in the receipt of broad-spectrum therapy warrant further investigation.
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Affiliation(s)
- Katherine E Goodman
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jonathan D Baghdadi
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Laurence S Magder
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mark Sutherland
- Division of Critical Care, Departments of Emergency Medicine and Internal Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | | | | | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Anthony D Harris
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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16
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Szymczak JE, Elle Saine M, Chiotos K, Keller SC, Newland J, Lautenbach E, Heil EL. 965. Prevalence and Drivers of Burnout Among Antimicrobial Stewardship Personnel in the United States: A Cross-Sectional Study. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Although antimicrobial stewardship (AS) personnel are faced with occupational stressors that may contribute to burnout, little is known about the degree to which they experience this work-related syndrome. Our objective was to characterize the prevalence of, and identify factors associated with, burnout among AS personnel practicing in United States (US) hospitals.
Methods
We conducted a cross-sectional survey in October-December 2021. AS personnel (physicians and pharmacists) were approached via email through four US-based professional organizations. Respondents self-administered a questionnaire measuring demographics, AS program structure, resources, and organizational climate. Burnout was measured using the Maslach Burnout Inventory, a 22-item validated instrument with three subscales. Burnout was defined as a dichotomous outcome based on the presence of high scores on the emotional exhaustion subscale along with either a high depersonalization score or low professional accomplishment score. Descriptive statistics and logistic regression analyses were performed.
Results
A total of 259 AS personnel completed the questionnaire. The majority of respondents were pharmacists (n=201; 78.2%), female (n=166; 64.3%) and worked in a teaching hospital (n=212, 84.1%). The median age was 36 (IQR, 32-41). Thirty-six percent (n=94 of 259) of respondents met the definition for burnout. There were no significant differences in burnout by respondent demographics or professional role. Significant drivers of burnout (P< 0.05) identified in univariable regression modeling included feeling as if AS is not an institutional priority, that hospital leadership is unsupportive of AS, prescriber resistance to AS recommendations is common, having unsupportive infectious diseases or pharmacy colleagues, the AS team does not work well together, and AS work is not intellectually stimulating.
Conclusion
Over one third of AS personnel in our sample met predefined standardized criteria for burnout. Contextual aspects of the work environment, including leadership, unsupportive peer climate and conflict were associated with burnout. There is a need to address factors that contribute to burnout in AS personnel to ensure an engaged workforce and to minimize turnover.
Disclosures
Jason Newland, MD, AHRQ: Grant/Research Support|Merck: Grant/Research Support|NIH: Grant/Research Support|PEW Charitable Trust: Grant/Research Support|Pfizer: Grant/Research Support.
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Affiliation(s)
- Julia E Szymczak
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - M Elle Saine
- University of Pennsylvania Perelman School of Medicine , Philadelphia, Pennsylvania
| | - Kathleen Chiotos
- Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Sara C Keller
- Johns Hopkins University School of Medicine , Baltimore, Maryland
| | - Jason Newland
- Washington University School of Medicine , Saint Louis, Missouri
| | | | - Emily L Heil
- University of Maryland School of Pharmacy , Baltimore, Maryland
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17
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Stickler M, Heil EL, Noval M. 1764. Accuracy of Penicillin Allergy Risk Severity Documentation in Surgical Patients. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Clinical guidelines for antimicrobial prophylaxis recommend use of cefazolin for most surgical procedures. Patients who are labeled penicillin (PCN) allergic are often prescribed second line agents, though cross-reactivity is less than 1%. PCN allergic patients have significantly higher rates of readmissions and healthcare-associated infections. Allergy documentation in the medical record is often incomplete or inaccurate, and many allergies can be de-labeled through history alone. Our study aimed to investigate accuracy of allergy risk assessment in PCN allergic patients and the impact on surgical antibiotic prophylaxis for quality improvement.
Methods
This was a retrospective observational cohort study among adult patients with a reported PCN allergy who underwent a surgical procedure from 3/2019-2/2020 at a single academic institution. The primary outcome was incidence of appropriate documentation of allergy risk severity. Secondary outcomes included receipt of beta-lactam for surgical prophylaxis and incidence of documentation to reflect tolerance. Allergy risk classification was considered appropriate if it aligned with institutional guidelines (Table 1).
Results
Of 2647 patients who underwent surgical procedures, 330 (12%) reported PCN allergy. Allergy risk severity was appropriately documented in 136 (41%) patients. 150 (45%) were mislabeled as “high” or “unknown” risk compared to reported reaction. 191 (58%) patients with reported PCN allergies received beta-lactam antibiotics peri-operatively. Allergy history had been updated to reflect tolerance in only 6% of patients who received cefazolin for surgical prophylaxis and in 21% who had received beta-lactams previously (Table 2). Table 2:Primary and Secondary Outcomes
Conclusion
Inaccurate documentation of allergy risk results in decreased first-line antimicrobial use in patients with reported PCN allergies. Documented PCN allergy risk severity was often incorrect and over 100 additional patients could have been labeled “low risk” based on reported reaction. 72% of patients could have received first-line beta-lactam prophylaxis per institutional guidelines. Interventions targeting allergy history documentation alone could positively impact antibiotic selection.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | - Emily L Heil
- University of Maryland School of Pharmacy , Baltimore, Maryland
| | - Mandee Noval
- University of Maryland Medical Center , Baltimore, Maryland
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18
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Mishuk AU, Strich JR, Warner S, Sun J, Malik S, Lawandi A, Kondo M, Satlin MJ, Chandorkar A, Heil EL, Morales MK, Mathur A, Timpone J, Wooten D, Sweeney D, Pan J, Raybould J, Bonne S, Colindres R, Boucher HW, Buckman S, Furukawa D, Uslan D, Hohmann SF, Kadri SS. 652. Ceftazidime-avibactam Alone or as Combination Therapy? Multicenter Retrospective Cohort Analysis of Clinical Outcomes in Patients with Carbapenem-resistant Gram-negative Infection. Open Forum Infect Dis 2022. [PMCID: PMC9752154 DOI: 10.1093/ofid/ofac492.704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Background Ceftazidime-avibactam (caz-avi), a novel β-lactam/β-lactamase inhibitor, is commonly utilized for carbapenem-resistant gram-negative infections (CR-GNI). However, the benefits vs risks of combining caz-avi with other agents are unclear. Methods In this retrospective cohort study, inpatients with CR-GNI treated with caz-avi were identified at 9 U.S. hospitals. The impact of caz-avi monotherapy (MT) or combination therapy (CT; i.e., any concomitant use of gram-negative-active antibiotics) was studied using logistic regression, controlling for baseline patient and hospital factors. The primary outcome was in-hospital mortality or discharge to hospice (death), and secondary outcomes were length of stay (LOS), resolution of infectious signs and symptoms (clinical response), 90-day recurrent infection and future caz-avi–resistant organism. An adjusted odds ratio (aOR) with 95% confidence interval (CI) was used to assess the primary and secondary outcomes. Results 328/499 (65.7%) patients received caz-avi as targeted therapy for a CR-GNI. Overall patients treated with MT and CT were similar at baseline and had comparable baseline demographics although patients treated with CT were more likely to be in the ICU and receive a concomitant empiric in vitro-concordant antibiotic (table 1). The most common organism was Klebsiella spp. (44.6%) followed by Pseudomonas aeruginosa (27.7%) (table 2). Concomitant gram-negative agents are shown in table 3. Overall, 92 (28.1%) patients died and CT (vs MT) displayed similar adjusted mortality risk (27.7% vs 28.7%; aOR [95%CI]: 0.67 [0.34-1.33]) and LOS (19 [9, 37] and 20 [9, 42.5] days). CT (vs MT) was associated with greater odds of clinical response (aOR: 2.25 [95%CI:1.15-4.41]). Among survivors, similar rates of 90-day recurrent infection (50/154 (32.5%) were observed in CT vs 18/82 (22.0%) in MT group (p=0.09) and 5 (2.19%) patients had future infection with a caz-avi–resistant pathogen (3 in CT and 2 in MT group).
![]() ![]() ![]() Conclusion Compared to patients with CR-GNI treated with caz-avi alone, those who received CT including caz-avy had similar survival and LOS but higher clinical response. The role of CT in the era of novel antibiotics warrants additional study. Disclosures Helen W. Boucher, MD, American Society of Microbiology: Honoraria|Elsevier: Honoraria|Sanford Guide: Honoraria.
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Affiliation(s)
- Ahmed Ullah Mishuk
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD
| | - Jeffrey R Strich
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Sarah Warner
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Junfeng Sun
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | - Seidu Malik
- Critical Care Medicine, National Institutes of Health Clinical Center, Bethesda, Maryland
| | | | - Maiko Kondo
- Division of Infectious Diseases, Department of Medicine, Lenox Hill Hospital - Northwell Health, New York, New York
| | | | | | - Emily L Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland
| | | | - Anisha Mathur
- Medstar Georgetown University Hospital, DC, District of Columbia
| | - Joseph Timpone
- Medstar Georgetown University Hospital, DC, District of Columbia
| | - Darcy Wooten
- Division of Infectious Diseases, University of San Diego Health System, San Diego, California
| | - Daniel Sweeney
- Division of Pulmonary Critical Care and Sleep Medicine, University of San Diego Health System, San Diego, California
| | - Jonathan Pan
- Division of Infectious Diseases, Virginia Commonwealth University, Richmond, Virginia
| | | | - Stephanie Bonne
- Department of Surgery, University Hospital-Newark, Rutgers, The State University of New Jersey, Newark, New Jersey
| | | | | | - Sara Buckman
- Department of Surgery, Washington University, St. Louis, Missouri
| | - Daisuke Furukawa
- Division of Infectious Disease, UCLA Medical Center, LA, California
| | - Daniel Uslan
- Division of Infectious Disease, UCLA Medical Center, LA, California
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19
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Gens KD, Singer RS, Dilworth TJ, Heil EL, Beaudoin AL. Antimicrobials in Animal Agriculture in the United States: A Multidisciplinary Overview of Regulation and Utilization to Foster Collaboration: On Behalf Of the Society of Infectious Diseases Pharmacists. Open Forum Infect Dis 2022; 9:ofac542. [PMID: 36340739 PMCID: PMC9629461 DOI: 10.1093/ofid/ofac542] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 10/11/2022] [Indexed: 01/01/2024] Open
Abstract
Given the complexity of antimicrobial resistance and the dire implications of misusing antimicrobials, it is imperative to identify accurate and meaningful ways to understand and communicate the realities, challenges, and opportunities associated with antimicrobial utilization and measurement in all sectors, including in animal agriculture. The objectives of this article are to (i) describe how antimicrobials are regulated and used in US animal agriculture and (ii) highlight realities, challenges, and opportunities to foster multidisciplinary understanding of the common goal of responsible antimicrobial use. Recognition of the realities of medicine, practice, and policy in the agricultural setting is critical to identify realistic opportunities for improvement and collaboration.
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Affiliation(s)
- Krista D Gens
- Department of Pharmacy, Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Randall S Singer
- University of Minnesota College of Veterinary Medicine, Saint Paul, Minnesota, USA
| | - Thomas J Dilworth
- Department of Pharmacy Services, Advocate Aurora Health, Milwaukee, Wisconsin, USA
| | - Emily L Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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20
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Traver EC, Heil EL, Schmalzle SA. “A cross-sectional analysis of linezolid in combination with methadone or buprenorphine as a cause of serotonin toxicity.”. Open Forum Infect Dis 2022; 9:ofac331. [PMID: 35899282 PMCID: PMC9310287 DOI: 10.1093/ofid/ofac331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 06/30/2022] [Indexed: 12/03/2022] Open
Abstract
Background Serotonin toxicity (also referred to as serotonin syndrome) results from medications that affect the neurotransmitter serotonin. The antibiotic linezolid and the opioids methadone and buprenorphine are all reported to cause serotonin toxicity, but the degree of risk with use of linezolid in combination with methadone or buprenorphine is unknown. Methods We conducted a retrospective cross-sectional analysis of adult patients hospitalized from November 2015 to October 2019 who were administered linezolid in combination with methadone and/or buprenorphine within 24 hours and a subgroup that received the combination for ≥3 days. Cases of serotonin toxicity were identified from the clinical notes in the electronic medical record and were classified as possible or definite based on the clinical record. The Hunter diagnostic criteria were retrospectively applied. Results There were 494 encounters in which linezolid was administered concurrently with methadone and buprenorphine. The mean patient age was 42.5 years, and 52.4% of encounters were of female patients. The mean duration of concurrent administration was 1.9 days. There were 106 encounters with a duration of concurrent administration ≥3 days (mean, 5.4 days). Two cases of possible serotonin toxicity and 0 cases of definite serotonin toxicity occurred; neither possible case met the Hunter criteria from the available information. Possible cases occurred in 0.40% of all encounters and 1.89% of encounters with ≥3 days of overlap (upper 1-sided 95% CI, 0.87% and 4.06%). Conclusions Serotonin toxicity occurring during the administration of linezolid in combination with methadone and/or buprenorphine occurred rarely among 494 hospital encounters, including 106 encounters with ≥3 days of overlap. Limitations include potential missed diagnoses of serotonin toxicity and short durations of overlap. Further study evaluating the short-term risk of this combination is needed.
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Affiliation(s)
- Edward C Traver
- Department of Medicine, Division of Infectious Disease, University of Maryland School of Medicine , Baltimore, MD 21201 , USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy , Baltimore, MD 21201 , USA
| | - Sarah A Schmalzle
- Department of Medicine, Division of Infectious Disease, University of Maryland School of Medicine , Baltimore, MD 21201 , USA
- Institute of Human Virology, University of Maryland School of Medicine , Baltimore, MD 21201 , USA
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21
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Goodman KE, Heil EL, Claeys KC, Banoub M, Bork JT. Real-World Antimicrobial Stewardship Experience in a Large Academic Medical Center: Using Statistical and Machine Learning Approaches to Identify Intervention “Hotspots” in an Antibiotic Audit and Feedback Program. Open Forum Infect Dis 2022; 9:ofac289. [PMID: 35873287 PMCID: PMC9297307 DOI: 10.1093/ofid/ofac289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 06/07/2022] [Indexed: 11/14/2022] Open
Abstract
ABSTRACT
Background
Prospective audit with feedback (PAF) is an impactful strategy for antimicrobial stewardship program (ASP) activities. However, because PAF requires reviewing large numbers of antimicrobial orders on a case-by-case basis, PAF programs are highly resource-intensive. The current study aimed to identify predictors of ASP intervention (i.e., feedback), and to build models to identify orders that can be safely bypassed from review, to make PAF programs more efficient.
Methods
We performed a retrospective cross-sectional study of inpatient antimicrobial orders reviewed by the University of Maryland Medical Center’s PAF program between 2017–2019. We evaluated the relationship between antimicrobial and patient characteristics with ASP intervention using multivariable logistic regression models. Separately, we built prediction models for ASP intervention using statistical and machine learning approaches and evaluated performance on held-out data.
Results
Across 17,503 PAF reviews, 4,219 (24%) resulted in intervention. In adjusted analyses, a clinical pharmacist on the ordering unit or receipt of an ID consult were associated with 17% and 56% lower intervention odds, respectively (aORs 0.83 and 0.44, P values ≤ 0.001). Fluoroquinolones had the highest adjusted intervention odds (aOR 3.22, 95% CI: 2.63–3.96). A machine learning classifier (C-statistic 0.76) reduced reviews by 49% while achieving 78% sensitivity. A “workflow simplified” regression model that restricted to antimicrobial class and clinical indication variables, two strong machine-learning-identified predictors, reduced reviews by one-third while achieving 81% sensitivity.
Conclusions
Prediction models substantially reduced PAF review caseloads while maintaining high sensitivities. Our results and approach may offer a blueprint for other ASPs.
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Affiliation(s)
- Katherine E Goodman
- Correspondence: Katherine E. Goodman, JD, PhD, University of Maryland School of Medicine, 10 S Pine St, Baltimore, MD 21201, USA ()
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jacqueline T Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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22
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Chang J, Patel D, Vega A, Claeys KC, Heil EL, Scheetz MH. Does calculation method matter for targeting vancomycin area under the curve? J Antimicrob Chemother 2022; 77:2245-2250. [PMID: 35640658 PMCID: PMC9890897 DOI: 10.1093/jac/dkac151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/13/2022] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES To assess differences in vancomycin AUC estimates from two common, clinically applied first-order pharmacokinetic equation methods compared with Bayesian estimates. METHODS A cohort of patients who received vancomycin and therapeutic drug monitoring was studied. First-order population pharmacokinetic equations were used to guide initial empirical dosing. After receipt of the first dose, patients had peak and trough serum levels drawn and steady-state AUC was estimated using first-order pharmacokinetic equations as standard care. We subsequently created a Bayesian model and used individual Empirical Bayes Estimates to precisely calculate vancomycin AUC24-48, AUC48-72 and AUC72-96 in this cohort. AUC at steady state (AUCSS) differences from the first-order methods were compared numerically and categorically (i.e. below, within or above 400-600 mg·h/L) to Bayesian AUCs, which served as the gold standard. RESULTS A total of 65 adult inpatients with 409 plasma samples were included in this analysis. A two-compartment intravenous infusion model with first-order elimination fit the data well. The mean of Bayesian AUC24-48 was not significantly different from AUC estimates from the two first-order pharmacokinetic equation methods (P = 0.68); however, Bayesian AUC48-72 and Bayesian AUC72-96 were both significantly different when compared with both first-order pharmacokinetic equation methods (P < 0.01 for each). At the patient level, categorical classifications of AUC estimates from the two first-order pharmacokinetic equation methods differed from categorizations derived from the Bayesian calculations. Categorical agreement was ∼50% between first-order and Bayesian calculations, with declining categorical agreement observed with longer treatment courses. Differences in categorical agreement between calculation methods could potentially result in different dose recommendations for the patient. CONCLUSIONS Bayesian-calculated AUCs between 48-72 and 72-96 h intervals were significantly different from first-order pharmacokinetic method-estimated AUCs at steady state. The various calculation methods resulted in different categorical classification, which could potentially lead to erroneous dosing adjustments in approximately half of the patients.
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Affiliation(s)
- Jack Chang
- Midwestern University College of Pharmacy, Department of Pharmacy Practice, Downers Grove, IL, USA
- Midwestern University College of Pharmacy, Pharmacometrics Center of Excellence, Downers Grove, IL, USA
- Northwestern Memorial Hospital, Department of Pharmacy, Chicago, IL, USA
| | - Dhara Patel
- Midwestern University College of Pharmacy, Department of Pharmacy Practice, Downers Grove, IL, USA
| | - Ana Vega
- Jackson Memorial Hospital, Department of Pharmacy, Miami, FL, USA
| | - Kimberly C Claeys
- University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD, USA
| | - Emily L Heil
- University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD, USA
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Abstract
Carbapenem-resistant Acinetobacter baumannii (CRAB) can cause significant infections with limited treatment options available. Falcone et al. (https://doi.org/10.1128/aac.02142-21) describe a single-center retrospective study comparing clinical outcomes among patients with CRAB infections treated with cefiderocol-containing versus colistin-containing regimens. Patients who received cefiderocol-containing regimens had lower 30-day mortality, though there are several limitations raised here, which make interpretation and applicability difficult.
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Affiliation(s)
- Sara M. Karaba
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth B. Hirsch
- Department of Experimental and Clinical Pharmacology, University of Minnesota College of Pharmacy, Minneapolis, Minnesota, USA
| | - Emily L. Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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24
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Reed BN, Devabhakthuni S, Gale SE, Heil EL, Hsu G, Martinelli AN, Bernhardi CL, Pires S, Yeung SYA. Selection by design: Using job analysis to guide the selection of postgraduate pharmacy residents. Am J Health Syst Pharm 2022; 79:1570-1579. [PMID: 35511822 DOI: 10.1093/ajhp/zxac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE To help ensure that we were accurately and consistently evaluating applicants to our postgraduate year 1 (PGY1) pharmacy residency program, we performed a job analysis to inform a redesign of our selection process. SUMMARY A diverse panel of subject matter experts from our program was convened to develop a task inventory; a list of knowledge, skills, abilities, and other characteristics necessary for success in our program; and behavioral snapshots representing especially strong or weak resident performance (ie, critical incidents). After achieving a priori thresholds of consensus, these items were used to augment our application screening instrument (eg, development of anchored rating scales), build an online supplemental application consisting of a personality test and situational judgment test, develop a work sample consisting of a patient case presentation, and enhance the structure of our interviews (eg, by asking a consistent pattern of questions for all candidates). Preceptors reported that the redesigned process was more organized, easier to complete, and facilitated greater rating consistency. CONCLUSION Job analysis represents an approach to designing selection processes that are more valid, reliable, transparent, and fair. Based on our experiences, recommendations for those who are considering changes to their selection process are provided.
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Affiliation(s)
- Brent N Reed
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | - Stormi E Gale
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Emily L Heil
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Grace Hsu
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | | | | | - Stephanie Pires
- University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Siu Yan A Yeung
- University of Maryland School of Pharmacy, Baltimore, MD, USA
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25
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Affiliation(s)
- Emily L Heil
- From the Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy (E.L.H.), and the Institute of Human Virology, University of Maryland School of Medicine (S.K.), Baltimore
| | - Shyam Kottilil
- From the Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy (E.L.H.), and the Institute of Human Virology, University of Maryland School of Medicine (S.K.), Baltimore
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26
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Heil EL, Bork JT, Abbo LM, Barlam TF, Cosgrove SE, Davis A, Ha DR, Jenkins TC, Kaye KS, Lewis JS, Ortwine JK, Pogue JM, Spivak ES, Stevens MP, Vaezi L, Tamma PD. Optimizing the Management of Uncomplicated Gram-Negative Bloodstream Infections: Consensus Guidance Using a Modified Delphi Process. Open Forum Infect Dis 2021; 8:ofab434. [PMID: 34738022 PMCID: PMC8561258 DOI: 10.1093/ofid/ofab434] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 08/19/2021] [Indexed: 12/24/2022] Open
Abstract
Background Guidance on the recommended durations of antibiotic therapy, the use of oral antibiotic therapy, and the need for repeat blood cultures remain incomplete for gram-negative bloodstream infections. We convened a panel of infectious diseases specialists to develop a consensus definition of uncomplicated gram-negative bloodstream infections to assist clinicians with management decisions. Methods Panelists, who were all blinded to the identity of other members of the panel, used a modified Delphi technique to develop a list of statements describing preferred management approaches for uncomplicated gram-negative bloodstream infections. Panelists provided level of agreement and feedback on consensus statements generated and refined them from the first round of open-ended questions through 3 subsequent rounds. Results Thirteen infectious diseases specialists (7 physicians and 6 pharmacists) from across the United States participated in the consensus process. A definition of uncomplicated gram-negative bloodstream infection was developed. Considerations cited by panelists in determining if a bloodstream infection was uncomplicated included host immune status, response to therapy, organism identified, source of the bacteremia, and source control measures. For patients meeting this definition, panelists largely agreed that a duration of therapy of ~7 days, transitioning to oral antibiotic therapy, and forgoing repeat blood cultures, was reasonable. Conclusions In the absence of professional guidelines for the management of uncomplicated gram-negative bloodstream infections, the consensus statements developed by a panel of infectious diseases specialists can provide guidance to practitioners for a common clinical scenario.
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Affiliation(s)
- Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Jacqueline T Bork
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Lilian M Abbo
- Department of Medicine, University of Miami Miller School of Medicine, Jackson Health System, Miami, Florida, USA
| | - Tamar F Barlam
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Sara E Cosgrove
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Angelina Davis
- Division of Infectious Diseases, Duke Antimicrobial Stewardship Outreach Network, Durham, North Carolina, USA
| | - David R Ha
- Department of Quality and Patient Safety, Stanford Antimicrobial Safety and Sustainability Program, Stanford, California, USA
| | | | - Keith S Kaye
- Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan, USA
| | - James S Lewis
- Department of Pharmacy, Oregon Health and Science University, Portland, Oregon, USA
| | - Jessica K Ortwine
- Department of Pharmacy, Parkland Health & Hospital System, Dallas, Texas, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Emily S Spivak
- Department of Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Michael P Stevens
- Department of Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA
| | - Liza Vaezi
- Department of Pharmacy, Virginia Mason Medical Center, Seattle, Washington, USA
| | - Pranita D Tamma
- Department of Pediatrics, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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27
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Affiliation(s)
- Emily L Heil
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy
| | - Neha Sheth Pandit
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy
| | - Gregory H Taylor
- Division of Infectious Diseases, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
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28
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Monogue ML, Heil EL, Aitken SL, Pogue JM. The role of tazobactam-based combinations for the management of infections due to extended-spectrum β-lactamase-producing Enterobacterales: Insights from the Society of Infectious Diseases Pharmacists. Pharmacotherapy 2021; 41:864-880. [PMID: 34689349 DOI: 10.1002/phar.2623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/17/2021] [Accepted: 08/22/2021] [Indexed: 11/07/2022]
Abstract
Extended-spectrum β-lactamase (ESBL)-producing Enterobacterales are a global threat to public health due to their antimicrobial resistance profile and, consequently, their limited available treatment options. Tazobactam is a sulfone β-lactamase inhibitor with in vitro inhibitory activity against common ESBLs in Enterobacterales, including CTX-M. However, the role of tazobactam-based combinations in treating infections caused by ESBL-producing Enterobacterales remains unclear. In the United States, two tazobactam-based combinations are available, piperacillin-tazobactam and ceftolozane-tazobactam. We evaluated and compared the roles of tazobactam-based combinations against ESBL-producing organisms with emphasis on pharmacokinetic/pharmacodynamic exposures in relation to MIC distributions and established breakpoints, clinical outcomes data specific to infection site, and considerations for downstream effects with these agents regarding antimicrobial resistance development. While limited data with ceftolozane-tazobactam are encouraging for its potential role in infections due to ESBL-producing Enterobacterales, further evidence is needed to determine its place in therapy. Conversely, currently available microbiologic, pharmacokinetic, pharmacodynamic, and clinical data do not suggest a role for piperacillin-tazobactam, and we caution clinicians against its usage for these infections.
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Affiliation(s)
- Marguerite L Monogue
- Department of Pharmacy, University of Texas Southwestern Medical Center, Dallas, Texas, USA
- Division of Infectious Diseases and Geographic Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Emily L Heil
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, Maryland, USA
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Samuel L Aitken
- Department of Pharmacy, Michigan Medicine, Ann Arbor, Michigan, USA
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
| | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, Michigan, USA
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29
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Fong G, Chahine EB, Justo JA, Narayanan N, Heil EL, Stover KR, Cho JC, Jenkins ZN, MacDougall C. Assessment of antimicrobial pharmacokinetics curricula across schools and colleges of pharmacy in the United States. J Am Coll Clin Pharm 2021. [DOI: 10.1002/jac5.1541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gary Fong
- Chapman University School of Pharmacy Irvine California USA
| | - Elias B. Chahine
- Palm Beach Atlantic University Lloyd L. Gregory School of Pharmacy West Palm Beach Florida USA
| | - Julie Ann Justo
- University of South Carolina College of Pharmacy Columbia South Carolina USA
| | - Navaneeth Narayanan
- Rutgers University Ernest Mario School of Pharmacy Piscataway New Jersey USA
| | - Emily L. Heil
- University of Maryland School of Pharmacy Baltimore Maryland USA
| | - Kayla R. Stover
- University of Mississippi School of Pharmacy Jackson Mississippi USA
| | | | | | - Conan MacDougall
- University of California San Francisco School of Pharmacy San Francisco California USA
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30
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Abstract
Bacterial resistance to carbapenem agents has reached alarming levels. Accordingly, collaborative efforts between national and international organizations and the pharmaceutical industry have led to an impressive expansion of commercially available β-lactam agents in recent years. No available agent comes close to the broad range of activity afforded by cefiderocol, a novel siderophore-cephalosporin conjugate. The novelty of and need for cefiderocol are clear, but available clinical data are conflicting, leaving infectious diseases specialists puzzled as to when to prescribe this agent in clinical practice. After a brief overview of cefiderocol pharmacokinetics and pharmacodynamics, safety data, cefiderocol susceptibility testing, and putative mechanisms of cefiderocol resistance, this review focuses on determining cefiderocol's role in the management of specific pathogens, including carbapenem-resistant Acinetobacter baumannii complex, carbapenem-resistant Pseudomonas aeruginosa, carbapenem-resistant Enterobacterales, and less commonly identified glucose-nonfermenting organisms such as Stenotrophomonas maltophilia, Burkholderia species, and Achromobacter species. Available preclinical, clinical trial, and postmarketing data are summarized for each organism, and each section concludes with our opinions on where to position cefiderocol as a clinical therapeutic.
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Affiliation(s)
- Erin K. McCreary
- Department of Medicine, Division of Infectious Diseases, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Emily L. Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Pranita D. Tamma
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Baltimore, Maryland, USA
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31
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Ritter LA, Britton N, Heil EL, Teeter WA, Murthi SB, Chow JH, Ricotta E, Chertow DS, Grazioli A, Levine AR. The Impact of Corticosteroids on Secondary Infection and Mortality in Critically Ill COVID-19 Patients. J Intensive Care Med 2021; 36:1201-1208. [PMID: 34247526 PMCID: PMC8442131 DOI: 10.1177/08850666211032175] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Corticosteroids are part of the treatment guidelines for COVID-19 and have been shown to improve mortality. However, the impact corticosteroids have on the development of secondary infection in COVID-19 is unknown. We sought to define the rate of secondary infection in critically ill patients with COVID-19 and determine the effect of corticosteroid use on mortality in critically ill patients with COVID-19. STUDY DESIGN AND METHODS One hundred and thirty-five critically ill patients with COVID-19 admitted to the Intensive Care Unit (ICU) at the University of Maryland Medical Center were included in this single-center retrospective analysis. Demographics, symptoms, culture data, use of COVID-19 directed therapies, and outcomes were abstracted from the medical record. The primary outcomes were secondary infection and mortality. Proportional hazards models were used to determine the time to secondary infection and the time to death. RESULTS The proportion of patients with secondary infection was 63%. The likelihood of developing secondary infection was not significantly impacted by the administration of corticosteroids (HR 1.45, CI 0.75-2.82, P = 0.28). This remained consistent in sub-analysis looking at bloodstream, respiratory, and urine infections. Secondary infection had no significant impact on the likelihood of 28-day mortality (HR 0.66, CI 0.33-1.35, P = 0.256). Corticosteroid administration significantly reduced the likelihood of 28-day mortality (HR 0.27, CI 0.10-0.72, P = 0.01). CONCLUSION Corticosteroids are an important and lifesaving pharmacotherapeutic option in critically ill patients with COVID-19, which have no impact on the likelihood of developing secondary infections.
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Affiliation(s)
- Lindsay A Ritter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Noel Britton
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - William A Teeter
- Department of Emergency Medicine, Program in Trauma/Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sarah B Murthi
- Department of Surgery, Program in Trauma/Surgical Critical Care, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine, Washington DC, USA
| | - Emily Ricotta
- National Institute of Allergy and Infectious Diseases Division of Intramural Research, Epidemiology Unit, National Institutes of Health, Bethesda, MD, USA
| | - Daniel S Chertow
- Critical Care Medicine Department, National Institutes of Health Clinical Center and Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, Bethesda, MD, USA
| | - Alison Grazioli
- National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD, USA.,Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrea R Levine
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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32
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Noval M, Heil EL, Williams P, Johnson JK, Claeys KC. The potential impact of discrepancies between automated susceptibility platforms and other testing metho`dologies for cefazolin in the treatment of Enterobacterales bloodstream infections. Diagn Microbiol Infect Dis 2021; 101:115483. [PMID: 34339950 DOI: 10.1016/j.diagmicrobio.2021.115483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/29/2021] [Accepted: 07/02/2021] [Indexed: 11/15/2022]
Abstract
Revised breakpoints for cefazolin (CFZ) against Enterobacterales may be difficult to implement with current automated susceptibility testing platforms and could falsely report organisms as susceptible, leading to inappropriate treatment for bloodstream infections (BSI). This was a retrospective cohort of adult patients with Enterobacterales BSI reported CFZ susceptible per Vitek®2. The primary outcome was the percentage susceptible by minimum inhibitory concentration (MIC) Gradient Test Strips and disk diffusion. Secondary outcomes included clinical outcomes between CFZ and non-CFZ-treated patients. Among 195 isolates reported CFZ-susceptible per Vitek®2, 84 (43.1%) were CFZ susceptible by MIC Gradient Test Strips vs 119 (61%) by disk diffusion. No difference was noted in 30-day all-cause mortality, secondary complications, or 30-day readmissions. Treatment failure was less likely to occur with source control (adjusted OR 0.06) and infectious disease consult (adjusted OR 0.37). There was a large degree of discrepancy between automated testing and manual methods; the clinical impact of this discrepancy warrants further investigation.
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Affiliation(s)
- Mandee Noval
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, MD, USA.
| | - Emily L Heil
- Department of Pharmacy, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Paula Williams
- Department of Laboratories and Pathology, University of Maryland Medical Center, Baltimore, MD, USA
| | - J Kristie Johnson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kimberly C Claeys
- Department of Pharmacy, University of Maryland School of Pharmacy, Baltimore, MD, USA
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33
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Rebechi MT, Heil EL, Luethy PM, Schmalzle SA. Streptococcus pyogenes Infective Endocarditis-Association With Injection Drug Use: Case Series and Review of the Literature. Open Forum Infect Dis 2021; 8:ofab240. [PMID: 34262985 PMCID: PMC8274460 DOI: 10.1093/ofid/ofab240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Streptococcus pyogenes, or Group A Streptococcus (GAS), is not considered a typical cause of infective endocarditis (IE), but has anecdotally been observed in unexpectedly high rates in people who inject drugs (PWID) at our institution. METHODS All cases of possible or definite GAS IE per Modified Duke Criteria in adults at an academic hospital between 11/15/2015 and 11/15/2020 were identified. Medical records were reviewed for demographics, comorbidities, treatment, and outcomes related to GAS IE. The literature on cases of GAS IE was reviewed. RESULTS Eighteen cases of probable (11) or definite (7) GAS IE were identified; the mean age was 38 years, and the population was predominantly female (56%) and Caucasian (67%), which is inconsistent with local population demographics. Sixteen cases were in people who inject drugs (PWID; 89%); 14 were also homeless, 6 also had HIV (33%), and 2 were also pregnant. Antibiotic regimens were variable due to polymicrobial bacteremia (39%). One patient underwent surgical valve replacement. Four patients (22%) died due to complications of infection. The literature review revealed 42 adult cases of GAS IE, only 17 of which were in PWID (24%). CONCLUSIONS The 16 cases of possible and definite GAS IE in PWID over a 5-year period in a single institution reported nearly doubles the number of cases in PWID from all previous reports. This suggests a potential increase in GAS IE particularly in PWID and PWH, which warrants further epidemiologic investigation.
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Affiliation(s)
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Paul M Luethy
- Department of Pathology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Sarah A Schmalzle
- University of Maryland School of Medicine, Baltimore, Maryland, USA
- Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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34
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Heil EL, Harris AD, Brown CH, Seung H, Thom KA, von Rosenvinge E, Sorongon S, Pineles L, Goodman KE, Leekha S. A Multi-Center Evaluation of Probiotic Use for the Primary Prevention of Clostridioides difficile infection. Clin Infect Dis 2021; 73:1330-1337. [PMID: 33972996 DOI: 10.1093/cid/ciab417] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Primary prevention of C. difficile infection (CDI) is a priority for hospitals and probiotics have the potential to interfere with colonization and infection with C. difficile. This study evaluated the impact of a computerized clinical decision support tool (CCDS) to prescribe probiotics for primary prevention of CDI among adult hospitalized patients. METHODS A CCDS tool was implemented into the electronic medical record at four hospitals prompting prescription of a probiotic preparation at the time of antibiotic prescription in high-risk patients in May 2019. Interrupted time series using segmented regression analysis was conducted to evaluate hospital-wide CDI incidence for the year pre- and post-CCDS implementation. In addition, multivariable logistic regression was used to evaluate CDI incidence in patients qualifying for probiotics in the pre- versus post-intervention periods adjusting for potential confounders. To adjust for potential differences in patients who received probiotics in the post-intervention period, propensity score matched pairs were developed to evaluate CDI risk by receipt of probiotics. RESULTS Quarterly CDI incidence increased over time post-intervention relative to baseline trends (slope change 1.4, 95% CI 0.9-1.9). The odds ratio (OR) of CDI was 1.41 in eligible patients post-intervention compared to pre-intervention (adjusted OR 1.41, 95% CI 1.11, 1.79). Propensity score matched analysis showed that patients who received probiotics did not have lower rates of CDI compared to those who did not receive probiotics (OR 1.46, 95% CI 0.87, 2.45). CONCLUSIONS Use of probiotics for primary prevention of CDI among adult inpatients receiving antibiotics is not supported.
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Affiliation(s)
- Emily L Heil
- University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD USA
| | - Anthony D Harris
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD USA
| | - Clayton H Brown
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD USA
| | - Hyunuk Seung
- University of Maryland School of Pharmacy, Department of Pharmacy Practice and Science, Baltimore, MD USA
| | - Kerri A Thom
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD USA
| | - Erik von Rosenvinge
- University of Maryland School of Medicine, Department of Medicine, Division of Gastroenterology, Baltimore, MD USA
| | - Scott Sorongon
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD USA
| | - Lisa Pineles
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD USA
| | - Katherine E Goodman
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD USA
| | - Surbhi Leekha
- University of Maryland School of Medicine, Department of Epidemiology and Public Health, Baltimore, MD USA
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Rhee C, Chiotos K, Cosgrove SE, Heil EL, Kadri SS, Kalil AC, Gilbert DN, Masur H, Septimus EJ, Sweeney DA, Strich JR, Winslow DL, Klompas M. Infectious Diseases Society of America Position Paper: Recommended Revisions to the National Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) Sepsis Quality Measure. Clin Infect Dis 2021; 72:541-552. [PMID: 32374861 DOI: 10.1093/cid/ciaa059] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Accepted: 01/20/2020] [Indexed: 12/18/2022] Open
Abstract
The Centers for Medicare & Medicaid Services' Severe Sepsis and Septic Shock Early Management Bundle (SEP-1) measure has appropriately established sepsis as a national priority. However, the Infectious Diseases Society of America (IDSA and five additional endorsing societies) is concerned about SEP-1's potential to drive antibiotic overuse because it does not account for the high rate of sepsis overdiagnosis and encourages aggressive antibiotics for all patients with possible sepsis, regardless of the certainty of diagnosis or severity of illness. IDSA is also concerned that SEP-1's complex "time zero" definition is not evidence-based and is prone to inter-observer variation. In this position paper, IDSA outlines several recommendations aimed at reducing the risk of unintended consequences of SEP-1 while maintaining focus on its evidence-based elements. IDSA's core recommendation is to limit SEP-1 to septic shock, for which the evidence supporting the benefit of immediate antibiotics is greatest. Prompt empiric antibiotics are often appropriate for suspected sepsis without shock, but IDSA believes there is too much heterogeneity and difficulty defining this population, uncertainty about the presence of infection, and insufficient data on the necessity of immediate antibiotics to support a mandatory treatment standard for all patients in this category. IDSA believes guidance on managing possible sepsis without shock is more appropriate for guidelines that can delineate the strengths and limitations of supporting evidence and allow clinicians discretion in applying specific recommendations to individual patients. Removing sepsis without shock from SEP-1 will mitigate the risk of unnecessary antibiotic prescribing for noninfectious syndromes, simplify data abstraction, increase measure reliability, and focus attention on the population most likely to benefit from immediate empiric broad-spectrum antibiotics.
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Affiliation(s)
- Chanu Rhee
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kathleen Chiotos
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Sara E Cosgrove
- Division of Infectious Diseases, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Sameer S Kadri
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Andre C Kalil
- Division of Infectious Diseases, Department of Internal Medicine, University of Nebraska School of Medicine, Omaha, Nebraska, USA
| | - David N Gilbert
- Division of Infectious Diseases, Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Henry Masur
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Edward J Septimus
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Department of Internal Medicine, Texas A&M College of Medicine, Houston, Texas, USA
| | - Daniel A Sweeney
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of California San Diego School of Medicine, San Diego, California, USA
| | - Jeffrey R Strich
- Critical Care Medicine Department, Clinical Center, National Institutes of Health, Bethesda, Maryland, USA
| | - Dean L Winslow
- Division of Infectious Diseases, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Michael Klompas
- Department of Population Medicine, Harvard Medical School/Harvard Pilgrim Health Care Institute, Boston, Massachusetts, USA.,Division of Infectious Diseases, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Mattingly TJ, Heil EL. The Economics of Penicillin Allergy Testing: Still Scratching the Value Surface. Clin Infect Dis 2021; 72:939-941. [PMID: 32107529 DOI: 10.1093/cid/ciaa195] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/24/2020] [Indexed: 01/02/2023] Open
Affiliation(s)
| | - Emily L Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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Abstract
Critically ill patients with sepsis or septic shock are at an increased risk of death. Early and aggressive interventions are essential for improving clinical outcomes. There are a number of therapeutic and practical challenges in the management of antimicrobials in patients with sepsis. These include the timely selection and administration of appropriate antimicrobials, significant physiological alterations that can influence antimicrobial pharmacokinetics, and significant interpatient variability of antimicrobial concentrations using standard dosing approaches. Understanding the impact of these factors on the probability of attaining pharmacokinetic-pharmacodynamic target goals is essential to guide optimal therapy. Using rapid diagnostic technology could facilitate timely selection of antimicrobials, and therapeutic drug monitoring would provide a more individualized dosing approach. Using an interdisciplinary sepsis team would also be beneficial in coordinating efforts to overcome the challenges encountered during this critical period to ensure optimal care.
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Affiliation(s)
- Kady Phe
- Baylor St Luke's Medical Center, Houston, Texas
| | - Emily L Heil
- University of Maryland School of Pharmacy, Baltimore, Maryland
| | - Vincent H Tam
- University of Houston College of Pharmacy, Houston, Texas
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38
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Blanco N, Robinson GL, Heil EL, Perlmutter R, Wilson LE, Brown CH, Heavner MS, Nadimpalli G, Lemkin D, Morgan DJ, Leekha S. Impact of a C. difficile infection (CDI) reduction bundle and its components on CDI diagnosis and prevention. Am J Infect Control 2021; 49:319-326. [PMID: 33640109 DOI: 10.1016/j.ajic.2020.10.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/19/2020] [Accepted: 10/20/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Published bundles to reduce Clostridioides difficile Infection (CDI) frequently lack information on compliance with individual elements. We piloted a computerized clinical decision support-based intervention bundle and conducted detailed evaluation of several intervention-related measures. METHODS A quasi-experimental study of a bundled intervention was performed at 2 acute care community hospitals in Maryland. The bundle had five components: (1) timely placement in enteric precautions, (2) appropriate CDI testing, (3) reducing proton-pump inhibitor (PPI) use, (4) reducing high-CDI risk antibiotic use, and (5) optimizing use of a sporicidal agent for environmental cleaning. Chi-square and Kruskal-Wallis tests were used to compare measure differences. An interrupted time series analysis was used to evaluate impact on hospital-onset (HO)-CDI. RESULTS Placement of CDI suspects in enteric precautions before test results did not change. Only hospital B decreased the frequency of CDI testing and reduced inappropriate testing related to laxative use. Both hospitals reduced the use of PPI and high-risk antibiotics. A 75% decrease in HO-CDI immediately postimplementation was observed for hospital B only. CONCLUSION A CDI reduction bundle showed variable impact on relevant measures. Hospital-specific differential uptake of bundle elements may explain differences in effectiveness, and emphasizes the importance of measuring processes and intermediate outcomes.
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Affiliation(s)
- Natalia Blanco
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD.
| | - Gwen L Robinson
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Emily L Heil
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
| | - Rebecca Perlmutter
- Emerging Infections Program, Maryland Department of Health, Baltimore, MD
| | - Lucy E Wilson
- Emerging Infections Program, Maryland Department of Health, Baltimore, MD
| | - Clayton H Brown
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Mojdeh S Heavner
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD
| | - Gita Nadimpalli
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel Lemkin
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD; VA Maryland Healthcare System, Baltimore, MD
| | - Surbhi Leekha
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD
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39
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Blackman AL, Joshi M, Doub J, Seung H, Banoub M, Claeys KC, Heil EL. Evaluation of Intra-Operative Topical Vancomycin and the Incidence of Acute Kidney Injury. Surg Infect (Larchmt) 2021; 22:810-817. [PMID: 33571051 DOI: 10.1089/sur.2020.303] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Background: Intra-operative topical vancomycin (VAN) is a strategy used to prevent surgical site infections (SSI). Although evidence supporting efficacy in SSI prevention is evolving, data describing safety, specifically acute kidney injury (AKI), are limited. The purpose of this study was to determine AKI incidence in patients who received intra-operative topical VAN. Patients and Methods: This is a retrospective study of adult inpatient encounters in which topical VAN was administered intra-operatively as powder/paste, beads, rods/cement/spacers, or unspecified topical route from February to July 2018. Patients were excluded for AKI or renal replacement therapy (RRT) at baseline or ≤2 serum creatinine (SCr) values post-surgery. The primary outcome was AKI incidence after intra-operative topical VAN, defined as increase in SCr ≥50% or 0.5 mg/dL from baseline or RRT initiation. Secondary outcomes included analysis of AKI risk factors and SSI incidence. Acute kidney injury risk factors were analyzed using multivariable logistic regression. Results: Five hundred thirty-four patient encounters met study criteria. Powder/paste were the most common topical VAN formulations (44.8%) with median doses of 2,000 (range, 1,000-26,000) mg. Acute kidney injury incidence was 8.8%. Independent risk factors for AKI were higher Charlson comorbidity index (adjusted odds ratio [aOR], 1.20 [range, 1.06-1.36]), concomitant systemic VAN (aOR, 2.44 [range, 1.29-4.58]), and doubling of total topical VAN dose (aOR, 1.51 [range, 1.13-2.03]). Conclusions: The incidence of AKI with intra-operative topical VAN is comparable to reported rates as systemic VAN. Clinicians may consider total topical VAN dose and concomitant systemic VAN to limit AKI incidence with topical VAN use.
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Affiliation(s)
- Alison L Blackman
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts, USA
| | - Manjari Joshi
- R.A. Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland, USA.,University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - James Doub
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Hyunuk Seung
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Sciences, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
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40
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Heil EL, Tamma PD. Cefiderocol: the Trojan horse has arrived but will Troy fall? Lancet Infect Dis 2021; 21:153-155. [PMID: 33058794 DOI: 10.1016/s1473-3099(20)30828-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Emily L Heil
- Department of Pharmacy, University of Maryland School of Pharmacy, Baltimore, MD 21201, USA.
| | - Pranita D Tamma
- Department of Pediatrics, Johns Hopkins Hospital, Baltimore, MD, USA
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41
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Barlow A, Heil EL, Claeys KC. Using an Ordinal Approach to Compare Outcomes Between Vancomycin Versus Ceftaroline or Daptomycin in MRSA Bloodstream Infection. Infect Dis Ther 2021; 10:605-612. [PMID: 33484408 PMCID: PMC7954948 DOI: 10.1007/s40121-021-00401-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/09/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction Vancomycin remains first-line therapy for methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections (BSI); however, its toxicity and reported clinical failures are well established. Binary efficacy endpoints evaluating alternative anti-MRSA therapies leave clinicians deciphering between segregated clinical and safety outcomes and do not provide a comprehensive patient-centered picture of comparative therapies. This study aimed to apply a novel methodology, desirability of outcomes ranking (DOOR), to compare anti-MRSA therapies. Methods This was a single-centered, retrospective, cohort of adult patients with MRSA BSI that received vancomycin, daptomycin, or ceftaroline. A previously developed DOOR for S. aureus BSI was adjusted and applied to this cohort to compare vancomycin-treated versus daptomycin/ceftaroline-treated patients. The DOOR had five mutually exclusive ranks: (1) alive without treatment failure, infectious complications, or grade 4 adverse events (AEs); (2) alive with any one of treatment failure, infectious complications, or grade 4 AE; (3) alive with two of treatment failure, infectious complications, or grade 4 AE; (4) alive with all three treatment failure, infectious complications, or grade 4 AE; or (5) deceased. Results A total of 43 vancomycin-treated and 13 daptomycin/ceftaroline-treated patients were included. Baseline clinical characteristics were similar, except for higher median serum creatinine in the daptomycin/ceftaroline cohort (0.76 [IQR 0.57, 1.11] vs 1.36 [IQR 1.09, 1.91] mg/dL, P = 0.03). Patients in the daptomycin/ceftaroline cohort had a 92% probability of better outcome using DOOR methodology. Patients treated with daptomycin/ceftaroline experienced less MRSA BSI persistence (0% vs 13.9%), MRSA BSI recurrence (7.8% vs 25.6%), grade 4 AEs (23.1% vs 46.5%), and in-hospital mortality (0% vs 9.3%). Conclusions Although limited by sample size, this study demonstrates the potential of DOOR to produce valuable, patient-centered results. Clinicians are encouraged to become familiar with appropriate use and interpretation of DOOR methodology as it will become an increasingly common endpoint in clinical trials.
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Affiliation(s)
- Ashley Barlow
- University of Maryland Medical Center, Baltimore, MD, USA
| | - Emily L Heil
- University of Maryland Medical Center, Baltimore, MD, USA.,University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Kimberly C Claeys
- University of Maryland Medical Center, Baltimore, MD, USA. .,University of Maryland School of Pharmacy, Baltimore, MD, USA.
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Heil EL, Bork JT. It Is a Marathon, Not a Sprint-Sustainability of Stewardship in ICUs. Crit Care Med 2021; 49:159-161. [PMID: 33337745 DOI: 10.1097/ccm.0000000000004714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Emily L Heil
- Division of Infectious Diseases, Department of Medicine, University of School of Maryland Medicine, Baltimore, MD
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Affiliation(s)
- Ilan S Schwartz
- Division of Infectious Diseases, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Erin K McCreary
- Department of Medicine, Division of Infectious Diseases, UPMC Health System and the University of Pittsburgh School of Medicine, Pittsburgh, PA 15213, USA
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Abstract
Introduction: Nosocomial pneumonias are the second most common healthcare-associated infections (HCAIs), often associated with the presence of Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Acinetobacter species, and Enterobacter species. Increasing use of carbapenems has led to an increase in the prevalence of carbapenem-resistant gram-negative organisms, such as carbapenem-resistant Enterobacterales (CRE), P. aeruginosa (CRPA), and Acinetobacter baumannii (CRAB), limiting treatment options for patients at high-risk of multi-drug resistant (MDR) gram-negative pathogens. Areas covered: The purpose of this review is to discuss the role of meropenem/vaborbactam, a beta-lactam combined with a novel non-beta-lactam cyclic boronic acid beta-lactamase inhibitor (BLI), for the treatment of nosocomial pneumonia based on its chemistry, pharmacokinetics/dynamics, microbiological spectrum of activity, mechanisms of resistance, safety, and clinical efficacy. Expert opinion: Currently, any utilization of meropenem/vaborbactam beyond its FDA-approved indication for complicated urinary tract infections is considered off-label use; however, based on the pulmonary penetration of meropenem/vaborbactam, it is highly likely to be a safe and effective alternative to more toxic agents, like aminoglycosides and polymixins, for targeted therapy in pulmonary infections due to CRE. Unfortunately, the multifactorial resistance pattern of CRPA and other non-lactose-fermenting gram-negative bacteria restricts activity against these organisms which are common pathogens implicated in nosocomial pneumonia.
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Affiliation(s)
- Lauren M Groft
- Department of Pharmacy Practice and Science, PGY2 Infectious Diseases Pharmacy Resident University of Maryland School of Pharmacy ,St. Baltimore, MD, USA
| | - Kimberly C Claeys
- Department of Pharmacy Practice and Science, Assistant Professor, University of Maryland School of Pharmacy 20 N Pine St. Baltimore , MD,USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, Associate Professor, University of Maryland School of Pharmacy 20 N Pine St. Baltimore , MD, USA
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Claeys KC, Brade KD, Heil EL. Should Therapeutic Monitoring of Vancomycin Based on Area under the Curve Become Standard Practice for Patients with Confirmed or Suspected Methicillin-Resistant Staphylococcus aureus Infection? The “Pro” Side: Correction. Can J Hosp Pharm 2020. [DOI: 10.4212/cjhp.v73i4.3030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Reed BN, Noel ZR, Heil EL, Shipper AG, Gardner AK. Surveying the selection landscape: A systematic review of processes for selecting postgraduate year 1 pharmacy residents and key implications. J Am Coll Clin Pharm 2020. [DOI: 10.1002/jac5.1334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Brent N. Reed
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
| | - Zachary R. Noel
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
| | - Emily L. Heil
- Department of Pharmacy Practice and Science University of Maryland School of Pharmacy Baltimore Maryland USA
| | - Andrea G. Shipper
- Health Sciences and Human Services Library University of Maryland Baltimore Baltimore Maryland USA
| | - Aimee K. Gardner
- Health Professions, Surgery Baylor College of Medicine Houston Texas USA
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Mouradjian MT, Heil EL, Sueng H, Pandit NS. Virologic suppression in patients with a documented M184V/I mutation based on the number of active agents in the antiretroviral regimen. SAGE Open Med 2020; 8:2050312120960570. [PMID: 33014372 PMCID: PMC7509719 DOI: 10.1177/2050312120960570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Accepted: 08/31/2020] [Indexed: 11/15/2022] Open
Abstract
Objectives: The optimal antiretroviral therapy for patients with the M184V/I mutation is not known. The primary objective of this study was to determine the efficacy of various antiretroviral therapies in patients with HIV and the M184V/I mutation based on the number of active antiretroviral agents. Methods: A retrospective chart review was conducted of 100 treatment-experienced patients harboring the M184V/I mutation seen at an urban HIV clinic. Efficacy was classified as percentage of patients with viral suppression defined as HIV RNA viral load <200 copies/mL at last measurement on current antiretroviral therapy, stratified by the number of active antiretroviral agents. Results: The primary outcome of viral suppression occurred in 70.6% (12/17) of patients on <2 active agents, 77.2% (44/57) on 2–2.5 active agents, and 69.2% (18/26) on 3 active agents. No significant difference was found between viral suppression and patients on <2 and 2–2.5 antiretroviral agents (odds ratio = 0.71, 95% confidence interval = (0.21, 2.39), p = 0.8) or between patients on 3 and 2–2.5 active agents (odds ratio = 0.66, 95% confidence interval = (0.23, 1.88), p = 0.7). The most commonly prescribed regimen consisted of a boosted protease inhibitor with an integrase strand transfer inhibitor and two nucleoside reverse transcriptase inhibitors, one of which being lamivudine or emtricitabine. Conclusion: Similar rates of viral suppression were observed in patients regardless of the number of active antiretroviral agents prescribed. Regimens containing less than 3 active agents may maintain virologic suppression in patients with the M184V/I mutation. Further studies are needed to determine optimal antiretroviral therapy for patients with the M184V/I mutation.
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Affiliation(s)
- Mallory T Mouradjian
- Department of Pharmacy Services, University of Maryland Medical Center, Baltimore, MD, USA.,Department of Pharmacy Services, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Hyunuk Sueng
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Neha Sheth Pandit
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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48
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Claeys KC, Heil EL, Hitchcock S, Johnson JK, Leekha S. Management of Gram-Negative Bloodstream Infections in the Era of Rapid Diagnostic Testing: Impact With and Without Antibiotic Stewardship. Open Forum Infect Dis 2020; 7:ofaa427. [PMID: 33134414 PMCID: PMC7585329 DOI: 10.1093/ofid/ofaa427] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/09/2020] [Indexed: 12/26/2022] Open
Abstract
Background Verigene Blood-Culture Gram-Negative is a rapid diagnostic test (RDT) that detects gram-negatives (GNs) and resistance within hours from gram stain. The majority of the data support the use of RDTs with antimicrobial stewardship (AMS) intervention in gram-positive bloodstream infection (BSI). Less is known about GN BSI. Methods This was a retrospective quasi-experimental (nonrandomized) study of adult patients with RDT-target GN BSI comparing patients pre-RDT/AMS vs post-RDT/pre-AMS vs post-RDT/AMS. Optimal therapy was defined as appropriate coverage with the narrowest spectrum, accounting for source and co-infecting organisms. Time to optimal therapy was analyzed using Kaplan-Meier and multivariable Cox proportional hazards regression. Results Eight-hundred thirty-two patients were included; 237 pre-RDT/AMS vs 308 post-RDT/pre-AMS vs 237 post-RDT/AMS, respectively. The proportion of patients on optimal antibiotic therapy increased with each intervention (66.5% vs 78.9% vs 83.2%; P < .0001). Time to optimal therapy (interquartile range) decreased with introduction of RDT: 47 (7.9–67.7) hours vs 24.9 (12.4–55.2) hours vs 26.5 (10.3–66.5) hours (P = .09). Using multivariable modeling, infectious diseases (ID) consult was an effect modifier. Within the ID consult stratum, controlling for source and ICU stay, compared with the pre-RDT/AMS group, both post-RDT/pre-AMS (adjusted hazard ratio [aHR], 1.34; 95% CI, 1.04–1.72) and post-RDT/AMS (aHR, 1.28; 95% CI, 1.01–1.64), improved time to optimal therapy. This effect was not seen in the stratum without ID consult. Conclusions With the introduction of RDT and AMS, both proportion and time to optimal antibiotic therapy improved, especially among those with an existing ID consult. This study highlights the beneficial role of RDTs in GN BSI.
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Affiliation(s)
- Kimberly C Claeys
- Department Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Emily L Heil
- Department Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | | | | | - Surbhi Leekha
- University of Maryland School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology & Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Vega A, Heil EL, Blackman A, Banoub M, Johnson JK, Leekha S, Claeys KC. Reply to Letters to the Editor. Pharmacotherapy 2020; 40:985-986. [PMID: 33112455 DOI: 10.1002/phar.2454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 06/11/2023]
Affiliation(s)
- Ana Vega
- Department of Pharmacy, Jackson Health System, Miami, Florida, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Alison Blackman
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
- Department of Pharmacy, Boston Medical Center, Boston, Massachusetts, USA
| | - Mary Banoub
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - J Kristie Johnson
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Surbhi Leekha
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
- University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Kimberly C Claeys
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
- Department of Pharmacy, University of Maryland Medical Center, Baltimore, Maryland, USA
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Abstract
Patients with sepsis present across a spectrum of infection sites and severity of illnesses requiring complex decision making at the bedside as to when prompt antibiotics are indicated and which regimen is warranted. Many hemodynamically stable patients with sepsis and low acuity of illness may benefit from further work up before initiating therapy, whereas patients with septic shock warrant emergent broad-spectrum antibiotics. The precise empiric regimen is determined by assessing patient and epidemiological risk factors, likely source of infection based on presenting signs and symptoms, and severity of illness. Hospitals should implement quality improvement measures to aid in the rapid and accurate diagnosis of septic patients and to ensure antibiotics are given to patients in an expedited fashion after antibiotic order.
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Affiliation(s)
- Jeffrey R Strich
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
- United States Public Health Service, Commissioned Corps, Rockville, Maryland, USA
| | - Emily L Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Henry Masur
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, Maryland, USA
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