Engaging patients in antimicrobial stewardship: co-designed educational tool to improve periprocedural care through de-implementation of guideline-discordant antimicrobial use

Effective de-implementation models often include replacement of an ineffective practice with an alternative. We co-developed patient education materials as a replacement strategy for inappropriate post-procedural antibiotics in cardiac device procedures. Lessons learned and developed materials may be used to promote infection prevention in other periprocedural settings.

[Diagnostic value of rapid exchange test in patients with peritoneal dialysis catheter dysfunction]

A total of 36 patients with suspected peritoneal dialysis (PD) catheter dysfunction in the First Hospital of China Medical University from June 2020 to August 2022 were included, and five patients with normal PD catheter were also included as the control group. There were 22 males and 19 females, and aged (45±21) years. The volume of rapid-phase drainage in the control and dysfunction groups was (2 086±65) and (1 181±637) ml, and the total drainage time was (15.2±1.3) and (38.3±14.9) min, respectively. The volume of rapid-phase drainage in the dysfunction group was reduced and the total drainage time was longer than that in the control group (both P<0.05). Compared with group with PD catheter migration, the duration of new bag instillation was prolonged, the drainage volume in the rapid-phase was reduced, the total drainage duration was prolonged, and the ultrafiltration volume was decreased in the group with PD catheter obstruction (all P<0.05). The rapid exchange test can provide an early preliminary diagnosis of PD catheter dysfunction and identify the type of catheter dysfunction.

Clinical outcomes after IL-6 blockade in patients with COVID-19 and HIV: a case series

BACKGROUND

In hospitalized people with HIV (PWH) there is an increased risk of mortality from COVID-19 among hospitalized PWH as compared to HIV-negative individuals. Evidence suggests that tocilizumab-a humanized monoclonal interleukin (IL)-6 receptor inhibitor (IL-6ri) antibody-has a modest mortality benefit when combined with corticosteroids in select hospitalized COVID-19 patients who are severely ill. Data on clinical outcomes after tocilizumab use in PWH with severe COVID-19 are lacking.

CASE PRESENTATION

We present a multinational case series of 18 PWH with COVID-19 who were treated with IL-6ri's during the period from April to June 2020. Four patients received tocilizumab, six sarilumab, and eight received an undocumented IL-6ri. Of the 18 patients in the series, 4 (22%) had CD4 counts < 200 cells/mm³; 14 (82%) had a suppressed HIV viral load. Eight patients (44%), all admitted to ICU, were treated for secondary infection; 5 had a confirmed organism. Of the four patients with CD4 counts < 200 cells/mm³, three were treated for secondary infection, with 2 confirmed organisms. Overall outcomes were poor-12 patients (67%) were admitted to the ICU, 11 (61%) required mechanical ventilation, and 7 (39%) died.

CONCLUSIONS

In this case series of hospitalized PWH with COVID-19 and given IL-6ri prior to the common use of corticosteroids, there are reports of secondary or co-infection in severely ill patients. Comprehensive studies in PWH, particularly with CD4 counts < 200 cells, are warranted to assess infectious and other outcomes after IL-6ri use, particularly in the context of co-administered corticosteroids.

Promoting de-implementation of inappropriate antimicrobial use in cardiac device procedures by expanding audit and feedback: protocol for hybrid III type effectiveness/implementation quasi-experimental study

Background

Despite a strong evidence base and clinical guidelines specifically recommending against prolonged post-procedural antimicrobial use, studies indicate that the practice is common following cardiac device procedures. Formative evaluations conducted by the study team suggest that inappropriate antimicrobial use may be driven by information silos that drive provider belief that antimicrobials are not harmful, in part due to lack of complete feedback about all types of clinical outcomes. De-implementation is recognized as an important area of research that can lead to reductions in unnecessary, wasteful, or harmful practices, such as excess antimicrobial use following cardiac device procedures; however, investigations into strategies that lead to successful de-implementation are limited. The overarching hypothesis to be tested in this trial is that a bundle of implementation strategies that includes audit and feedback about direct patient harms caused by inappropriate prescribing can lead to successful de-implementation of guideline-discordant care.

Methods

We propose a hybrid type III effectiveness-implementation stepped-wedge intervention trial at three high-volume, high-complexity VA medical centers. The main study intervention (an informatics-based, real-time audit-and-feedback tool) was developed based on learning/unlearning theory and formative evaluations and guided by the integrated-Promoting Action on Research Implementation in Health Services (i-PARIHS) Framework. Elements of the bundled and multifaceted implementation strategy to promote appropriate prescribing will include audit-and-feedback reports that include information about antibiotic harms, stakeholder engagement, patient and provider education, identification of local champions, and blended facilitation. The primary study outcome is adoption of evidence-based practice (de-implementation of inappropriate antimicrobial use). Clinical outcomes (cardiac device infections, acute kidney injuries and Clostridioides difficile infections) are secondary. Qualitative interviews will assess relevant implementation outcomes (acceptability, adoption, fidelity, feasibility).

Discussion

De-implementation theory suggests that factors that may have a particularly strong influence on de-implementation include strength of the underlying evidence, the complexity of the intervention, and patient and provider anxiety and fear about changing an established practice. This study will assess whether a multifaceted intervention mapped to identified de-implementation barriers leads to measurable improvements in provision of guideline-concordant antimicrobial use. Findings will improve understanding about factors that impact successful or unsuccessful de-implementation of harmful or wasteful healthcare practices.

Trial registration

ClinicalTrials.govNCT05020418

Pulmonary Manifestations of Parasitic Diseases in Children

Parasites can cause respiratory symptoms through focal or diffuse lung involvement, depending on the location of the parasite and the host's immune response. Pulmonary involvement can be a major feature of some parasitic infections or a complication during transpulmonary larval migration. Parasites should be included in the differential diagnosis of common lung diseases, especially in the presence of peripheral eosinophilia or extrapulmonary symptoms (abdominal pain, diarrhea, jaundice, skin lesions).

Prevalence of Intestinal Parasites in a Low-Income Texas Community

Strongyloidiasis affects an estimated hundreds of millions of people worldwide, with infection possibly persisting for life without appropriate therapy because of the helminth's unique autoinfection cycle. Like other soil-transmitted helminths, because of the environmental conditions required for the life cycle of Strongyloides stercoralis, this parasite is endemic to tropical, subtropical, and temperate countries and areas with inadequate sanitation infrastructure. Given continued poverty and that nearly one in five American homes are lacking proper sanitation systems, many U.S. regions are at risk for intestinal parasites. A central Texas community was chosen as the study site, given previous reports of widespread sanitation failure, degree of poverty, and community willingness to participate. A total of 92 households were surveyed and residents tested for nine intestinal parasites using a multi-parallel quantitative real-time polymerase chain reaction and ELISA serology. From 43 stool samples, 27 (62.8%) tested positive for Blastocystis spp. and one (2.3%) for Giardia lamblia. From 97 serum samples, Strongyloides serology detected 16 (16.5%) positive individuals. These high rates of heterokont and helminthic laboratory findings in a peri-urban central Texas community suggest several key policy implications, including that strongyloidiasis should be added to the Texas notifiable conditions list, that clinical suspicion for this infection should be heightened in the region, and that residents without access to functioning and sustainable sanitation infrastructure should be provided that access as a basic human right and to promote public health.

376. Effect of Parasitic Infections on Gut Epithelial Barrier and Immune Activation among Foreign-Born HIV-infected Patients

Background

Strongyloides stercoralis often causes an asymptomatic infection despite continuous autoinfection for the lifetime of the host. Both HIV and recurrent enteric parasitic infections cause gut damage and increased microbial translocation, but little is known about the effects of co-infection. We aimed to evaluate changes in immune activation, mucosal damage, and microbial translocation in people with HIV-1 (PWH) and parasite co-infection.

Methods

In this pilot prospective cohort study, we enrolled foreign-born PWH on suppressive antiretroviral therapy (ART) in an ambulatory clinic in Houston, Texas. We evaluated serum Strongyloides IgG using ELISA with an S. stercoralis-specific recombinant protein. Intestinal fatty acid-binding protein (I-FABP), soluble CD14 (sCD14), sCD163, IL-6, and sTNFRII were analyzed as markers of enterocyte turnover, inflammation, and immune activation. Non-parametric tests were used for analysis.

Results

52 participants born in 14 countries were enrolled February–March 2019. Median CD4 count was 464/uL [95% CI 315–598]. Fourteen (27%) were positive for Strongyloides IgG. Strongyloides IgG levels correlated positively with sCD14 levels [r=0.36; P = 0.008]. Strongyloides+ participants had significantly higher sCD14 levels compared with Strongyloides− participants [1.67 vs. 1.48 μg/mL, P = 0.031]. Among the Strongyloides+ participants, Strongyloides IgG levels correlated with sCD163 levels [r=0.65, P = 0.026]. There were no difference in the other biomarkers. Logistical regression analysis showed that predictors of Strongyloides+ include absolute eosinophil count (AEC) (OR 1.45 for every 100 increase of AEC [95% CI: 1.02, 2.15; P = 0.047]). CD4 count, number of years living in the United States, country of origin, and years from HIV diagnosis were not associated with test positivity.

Conclusion

Strongyloides co-infection is common among foreign-born PWH and may contribute to chronic monocyte/macrophage activation, a predictor of morbidity and mortality in PWH. Future directions include stool PCR confirmation of these infections, continued enrollment, and follow-up assays 6 months after treatment of Strongyloides to determine the impact on inflammation and risk of co-morbidities.

Disclosures

All authors: No reported disclosures.

Transposable elements and tumor progression

Although the concept that transposable elements (TEs) have the potential to enhance their host genomic evolution is widely accepted, it is still generally assumed that TEs primarily owe their prosperity to replicative advantage because the immediate effects on their hosts are generally harmful. To mitigate deleterious impact, hosts employ a cosuppression strategy to tame these perilous elements. The peculiarity of this strategy, however, is that TEs, as targets of suppression, also serve as primary components of this 'TE immune system'. Based on this view, we propose a possible mechanism whereby TEs are involved in tumor progression.

Different effects of toosendanin on perineurially recorded Ca(2+) currents in mouse and frog motor nerve terminals

By perineurial recording, the effects of toosendanin (TSN), a presynaptic blocker, on nerve terminal calcium currents (I(Ca)) were observed in innervated triangularis sterni of the mouse and cutaneous pectoris of the frog. It was found that TSN blocked the slow component of I(Ca) insensitive to nifedipine and omega-conotoxin-GVIA, and increasing the extracellular Ca(2+) concentration partially antagonized the inhibitory effect in mouse motor nerve terminals. However, in the frog, TSN increased the slow component of I(Ca) and this effect disappeared in the presence of nifedipine in perfusion solution. Based on previous data showing that the slow component of I(Ca) were mediated by different subtypes of calcium channels in mouse and frog motor nerve terminals, we presume that TSN could exercise different effects on various subtypes of calcium channels.

[Studies on the chemical constituents from Tribulus terrestris]

AIM

To investigate the chemical constituents of the fruit of Tribulus terrestris J..

METHODS

Various chromatographic techniques were used to separate the chemical constituents. ESIMS, IR, 1HNMR, 13CNMR and HMBC were used to determine the structures of the isolated constituents.

RESULTS

Two new compounds were isolated from the fruits of Tribulus terrestris J. and were identified as neohecogenin-3-O-beta-D-glucopyranosyl (1-->2)-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (I); neohecogenin-3-O-beta-D-glucopyranosyl (1-->4)-beta-D-galactopyranoside (II).

CONCLUSION

Compounds I and II are new steroidal saponins.

Measurement of cylindrical particles with phase Doppler anemometry

Light scattering from cylindrical particles has been described with geometric optics. The feasibility of determining the particle diameter with a planar phase Doppler anemometer has been examined by simulations and experiments. In particular, the influence of particle orientation on measurability and measurement accuracy has been investigated. Some recommendations for realizing a practical-measurement instrument have been presented.