Clinical impact of pharmacist-directed antimicrobial stewardship guidance following blood culture rapid diagnostic testing

BACKGROUND

Rapid diagnostic testing (RDT) has been shown to be associated with improved clinical outcomes.

AIM

To evaluate the clinical outcomes of using RDT paired with well-defined pharmacist-directed antimicrobial stewardship programme (ASP) guidance to achieve targeted treatment in patients with bacteraemia.

METHODS

In this quasi-study, a retrospective (pre-intervention) phase was compared with a prospective (post-intervention) phase. Adult patients with positive blood cultures identified using the BacT/ALERT system were included. Bacterial identification and susceptibility were provided by VITEK 2. During the post-intervention phase, Verigene ASP guidance was developed to optimize antibiotic selection. Pharmacists received the results from the microbiology laboratory, evaluated the appropriateness of current therapy (if any), and communicated the recommended antimicrobial therapy to the treating physician accordingly.

FINDINGS

The cohort consisted of 164 patients in the pre-intervention group and 148 patients in the post-intervention group. When comparing the post-intervention period with the pre-intervention period, the median time to culture identification was 22 vs 96 h (P<0.0001), median time to targeted antibiotics was 2 vs 22 h (P<0.0001), median time for antibiotic de-escalation was 12.2 vs 27 h (P<0.0001), and median time to escalation was 1.3 vs 24 h (P<0.003), respectively. In-hospital mortality and 30-day re-admission were significantly lower in the post-intervention group (P<0.003 and 0.034, respectively). Length of hospital stay was significantly shorter in the post-intervention group (6.5 vs 8 days; P=0.03).

CONCLUSION

Rapid identification of bacteraemia combined with a pharmacist's recommendation as an ASP initiative significantly improved time to optimal therapy, and may have decreased the risk of mortality and re-admission.

Fine grained compositional analysis of Port Everglades Inlet microbiome using high throughput DNA sequencing

BACKGROUND

Similar to natural rivers, manmade inlets connect inland runoff to the ocean. Port Everglades Inlet (PEI) is a busy cargo and cruise ship port in South Florida, which can act as a source of pollution to surrounding beaches and offshore coral reefs. Understanding the composition and fluctuations of bacterioplankton communities ("microbiomes") in major port inlets is important due to potential impacts on surrounding environments. We hypothesize seasonal microbial fluctuations, which were profiled by high throughput 16S rRNA amplicon sequencing and analysis.

METHODS & RESULTS

Surface water samples were collected every week for one year. A total of four samples per month, two from each sampling location, were used for statistical analysis creating a high sampling frequency and finer sampling scale than previous inlet microbiome studies. We observed significant differences in community alpha diversity between months and seasons. Analysis of composition of microbiomes (ANCOM) tests were run in QIIME 2 at genus level taxonomic classification to determine which genera were differentially abundant between seasons and months. Beta diversity results yielded significant differences in PEI community composition in regard to month, season, water temperature, and salinity. Analysis of potentially pathogenic genera showed presence of Staphylococcus and Streptococcus. However, statistical analysis indicated that these organisms were not present in significantly high abundances throughout the year or between seasons.

DISCUSSION

Significant differences in alpha diversity were observed when comparing microbial communities with respect to time. This observation stems from the high community evenness and low community richness in August. This indicates that only a few organisms dominated the community during this month. August had lower than average rainfall levels for a wet season, which may have contributed to less runoff, and fewer bacterial groups introduced into the port surface waters. Bacterioplankton beta diversity differed significantly by month, season, water temperature, and salinity. The 2013-2014 dry season (October-April), was warmer and wetter than historical averages. This may have driven significant differences in beta diversity. Increased nitrogen and phosphorous concentrations were observed in these dry season months, possibly creating favorable bacterial growth conditions. Potentially pathogenic genera were present in the PEI. However their relatively low, non-significant abundance levels highlight their relatively low risk for public health concerns. This study represents the first to sample a large port at this sampling scale and sequencing depth. These data can help establish the inlet microbial community baseline and supplement the vital monitoring of local marine and recreational environments, all the more poignant in context of local reef disease outbreaks and worldwide coral reef collapse in wake of a harsh 2014-16 El Niño event.

Dynamics of marine bacterial community diversity of the coastal waters of the reefs, inlets, and wastewater outfalls of southeast Florida

Coastal waters adjacent to populated southeast Florida possess different habitats (reefs, oceanic inlets, sewage outfalls) that may affect the composition of their inherent microbiomes. To determine variation according to site, season, and depth, over the course of 1 year, we characterized the bacterioplankton communities within 38 nearshore seawater samples derived from the Florida Area Coastal Environment (FACE) water quality survey. Six distinct coastal locales were profiled – the Port Everglades and Hillsboro Inlets, Hollywood and Broward wastewater outfalls, and associated reef sites using culture-independent, high-throughput pyrosequencing of the 16S rRNA V4 region. More than 227,000 sequences helped describe longitudinal taxonomic profiles of marine bacteria and archaea. There were 4447 unique operational taxonomic units (OTUs) identified with a mean OTU count of 5986 OTUs across all sites. Bacterial taxa varied significantly by season and by site using weighted and unweighted Unifrac, but depth was only supported by weighted Unifrac, suggesting a change due to presence/absence of certain OTUs. Abundant microbial taxa across all samples included Synechococcus, Pelagibacteraceae, Bacteroidetes, and various Proteobacteria. Unifrac analysis confirmed significant differences at inlet sites relative to reef and outfalls. Inlet-based bacterioplankton significantly differed in greater abundances of Rhodobacteraceae and Cryomorphaceae, and depletion of SAR406 sequences. This study also found higher counts of Firmicutes, Chloroflexi, and wastewater associated SBR1093 bacteria at the outfall and reef sites compared to inlet sites. This study profiles local bacterioplankton populations in a much broader context, beyond culturing and quantitative PCR, and expands upon the work completed by the National Oceanic and Atmospheric Administration FACE program.

The relationship between the ultrasonographic diagnosis of innocent amniotic band development and pregnancy outcomes

OBJECTIVE

To determine the importance of amniotic bands diagnosed ultrasonographically and their relationship to pregnancy outcome.

METHODS

We reviewed retrospectively the ultrasonographic records at State University of New York Health Science Center at Brooklyn and Kings County Hospital Center, identifying 25 cases of amniotic band diagnosed during 1986-1990. Cases were compared with 50 controls who had ultrasound evaluation at the same gestational age. Outcomes studied included fetal anomalies, obstetric factors or complications, pregnancy outcome, and maternal factors that may have predisposed to the formation of bands.

RESULTS

All cases had unrestricted fetal movement on the index sonogram. No fetal abnormalities were observed in either the case or control series. The groups were not significantly different in terms of maternal risk factors, but significant differences were found for delivery at less than 37 weeks and birth weight less than 2500 g.

CONCLUSION

Ultrasonographic diagnosis of an amniotic band in connection with sonographic findings of normal fetal anatomy may be a risk factor for preterm delivery and low birth weight. No association between amniotic band development and fetal anomalies was observed.

Immunocytochemical estrogen and progestin receptor assays in breast cancer with monoclonal antibodies. Histopathologic, demographic, and biochemical correlations and relationship to endocrine response and survival

Breast cancer specimens from 600 women were assayed for estrogen receptors (ER) using an immunocytochemical assay (ICA) employing the monoclonal antiestrophilin antibody H222 Sp gamma. Results showed significant correlation with biochemical ER determinations as well as with tumor grade and menopausal status. In 449 cases, results of progesterone receptor assay by ICA using the monoclonal anti-PgR antibody KD 68, also correlated significantly with biochemical PgR measurements. The ERICA/PgRICA positivity was significantly more frequent in postmenopausal white women. Colloid carcinomas were most likely to be ERICA positive and PgRICA positive whereas medullary carcinomas were most often negative. In 47 patients with advanced mammary carcinoma, results of ERICA and PgRICA were more closely related to endocrine response than those of ER and PgR by dextran-coated charcoal assay (DCC). In 339 women with Stage I or Stage II breast cancer, ERICA was significantly associated with disease-free survival. Analysis by Cox's proportional hazard model, however, showed PgRICA to be the best predictor of survival and disease-free survival in 197 women at the same stages of disease. These data indicate that ICA is more predictive of prognosis than biochemical ER and PgR. The ease of ICA performance coupled with these results indicate that the method is an acceptable substitute for DCC in analyzing breast cancers for ER/PgR.

Histochemical estrogen binding. An independent predictor of recurrence and survival in stage II breast cancer

Cox's proportional hazards regression model was used to analyze the prognostic significance of multiple variables affecting recurrence and survival in patients with Stage II breast cancer. Among the variables were biochemical estrogen (ER) and progesterone receptor (PgR) values and results of a histochemical estrogen-binding assay using a fluoresceinated bovine serum albumin-estradiol conjugate where carrier and label were bound at position 17. In 190 cases ER and PgR were not found to be significantly associated with either disease recurrence or patient survival. On the other hand, patients with tumors that were demonstrably "rich" in estradiol ligand conjugate binding by histochemistry experienced both a longer disease-free interval (P less than 0.03) and survival (P less than 0.02) than did patients whose tumors were "poor" in conjugate binding or showed a heterogeneous population of positively and negatively stained cells. A patient with a tumor rich in estrogen binding was five times more likely to survive than a patient with a neoplasm that was poor in estrogen binding by histochemistry. These results indicate that the histochemical technique used provides new and independent parameters for determination of prognosis in Stage II breast cancer.