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Smith EEA, Nachimuthu N, Flynn J, Balasubramanyam A, Negrete JA, Trautner BW, Al Mohajer M. Assessing clinicians' and trainees' knowledge and practice of the IDSA guidelines for asymptomatic bacteriuria in older adults. Infect Control Hosp Epidemiol 2024; 45:664-666. [PMID: 38251669 DOI: 10.1017/ice.2023.257] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
A survey of advanced practice clinicians (APCs), physicians, residents, and medical students at an academic medical center and community practices in southeastern Texas revealed a gap in knowledge and practice related to testing and treatment for asymptomatic bacteriuria (ASB) in older adults.
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Affiliation(s)
| | | | - John Flynn
- Baylor College of Medicine, Houston, Texas
- CommonSpirit Health Texas Division, Houston, Texas
| | | | | | - Barbara W Trautner
- Michael E. DeBakey Veterans Affairs' Medical Center, Houston, Texas
- Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
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2
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Wang MC, Zhou KJ, Shay SL, Herlihy JP, Siddique MA, Trevino Castillo S, Lasco TM, Barrett M, Al Mohajer M. The impact of a blood-culture diagnostic stewardship intervention on utilization rates and antimicrobial stewardship. Infect Control Hosp Epidemiol 2024; 45:670-673. [PMID: 38088164 DOI: 10.1017/ice.2023.265] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
Blood-culture overutilization is associated with increased cost and excessive antimicrobial use. We implemented an intervention in the adult intensive care unit (ICU), combining education based on the DISTRIBUTE algorithm and restriction to infectious diseases and ICU providers. Our intervention led to reduced blood-culture utilization without affecting safety metrics.
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Affiliation(s)
- Melinda C Wang
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Kelvin J Zhou
- Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Sabra L Shay
- Premier Inc, Department of Clinical Intelligence, Charlotte, North Carolina
| | - James P Herlihy
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Baylor St Luke's Medical Center, Houston, Texas
| | - Muhammad A Siddique
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Baylor St Luke's Medical Center, Houston, Texas
| | - Sergio Trevino Castillo
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Baylor St Luke's Medical Center, Houston, Texas
| | - Todd M Lasco
- Baylor St Luke's Medical Center, Houston, Texas
- Department of Pathology, Baylor College of Medicine, Houston, Texas
| | | | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, Texas
- Baylor St Luke's Medical Center, Houston, Texas
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Al Mohajer M, Samarasundera E, Gonçalves J, Heath A. Analyzing the relationship between socioeconomic deprivation and outpatient Medicare Part D fluoroquinolone claim rates in Texas. Antimicrob Steward Healthc Epidemiol 2024; 4:e40. [PMID: 38562515 PMCID: PMC10983052 DOI: 10.1017/ash.2024.38] [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] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 02/22/2024] [Accepted: 02/22/2024] [Indexed: 04/04/2024]
Abstract
Introduction Only a few studies have assessed the relationship between deprivation and excessive antibiotic use. In Texas, antimicrobial prescription rates are particularly high compared with the rest of the US. This study analyzed the association between local area socioeconomic deprivation and providers' fluoroquinolone claim rates among beneficiaries 65 years and older in Texas. Methods This ecological study utilized provider- and area-level data from Medicare Part D Prescribers and the Social Deprivation Index (SDI) repositories. Negative binomial regression models were employed to evaluate the relationship between provider- and area-level characteristics (prescriber's gender, specialty, rural-urban community area, beneficiaries' demographics, area-level population, and SDI) and fluoroquinolone claim rates per 1,000 beneficiaries. Results A total of 11,996 providers were included. SDI (IRR 0.98, 95% CI 0.97-0.99) and male providers (IRR 0.96, 95% CI 0.94-0.99) were inversely associated with claim rates. In contrast, several factors were associated with higher claim rates, including non-metropolitan areas (1.04, 95% CI 1.00-1.09), and practices with a high proportion of male (IRR 1.12, 95% CI 1.10-1.14), Black (IRR 1.05, 95% CI 1.03-1.07), or Medicaid beneficiaries (IRR 1.15, 95% CI 1.12-1.17). Effect modification was observed between SDI and rurality, with higher SDI in non-metropolitan areas associated with higher claim rates, whereas SDI in metropolitan areas was inversely related to claim rates. Conclusion Lower fluoroquinolone claim rates were observed among Texas Medicare providers in metropolitan areas with higher SDI. Conversely, higher rates were observed in rural areas with higher SDI. More studies are needed to understand the underlying causes of this variation and develop effective stewardship interventions.
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Affiliation(s)
- Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Edgar Samarasundera
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
| | - Judite Gonçalves
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, UK
- NOVA National School of Public Health, Public Health Research Centre, Comprehensive Health Research Center, CHRC, NOVA University Lisbon, Lisbon, Portugal
| | - Alicia Heath
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
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Kelly G, Hudson M, Apple B, Bundage D, Lembcke B, Lasco T, Al Mohajer M. Discontinuation of contact precautions in patients with hospital-acquired MRSA and VRE infections during the COVID-19 pandemic: A multi-center experience. J Infect Prev 2024; 25:33-37. [PMID: 38362111 PMCID: PMC10866122 DOI: 10.1177/17571774231208312] [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: 02/09/2022] [Accepted: 10/02/2023] [Indexed: 02/17/2024] Open
Abstract
Variations in the literature support the benefit of contact precautions for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) infections in the hospital setting. During personal protective equipment shortages throughout the COVID-19 pandemic, contact precautions were discontinued for MRSA and VRE-infected patients. Rates of hospital-acquired MRSA and VRE infections were compared before and after this intervention, along with hand hygiene proportions. Contact precaution discontinuation did not lead to an increase in hospital-acquired MRSA or VRE infections.
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Affiliation(s)
- Gillean Kelly
- Department of Medicine, Baylor College of Medicine School of Medicine, Houston, TX, USA
| | - Marisa Hudson
- Department of Medicine, Baylor College of Medicine School of Medicine, Houston, TX, USA
| | - Bridget Apple
- St Luke’s Health Sugar Land Hospital, Sugar Land, TX, USA
| | | | | | - Todd Lasco
- Baylor St Luke’s Medical Center, Houston, TX, USA
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine School of Medicine, Houston, TX, USA
- Baylor St Luke’s Medical Center, Houston, TX, USA
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5
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Centeno FH, Hamdi AM, Lasco TM, Al Mohajer M. Detection of invasive Bartonella infections with next-generation sequencing of microbial cell-free DNA. Antimicrob Steward Healthc Epidemiol 2024; 4:e20. [PMID: 38415091 PMCID: PMC10897719 DOI: 10.1017/ash.2024.16] [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] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 02/29/2024]
Abstract
We report 9 patients with invasive Bartonella infections, including 5 with endocarditis, who were diagnosed with microbial cell-free DNA next-generation sequencing and Bartonella serology studies. Diagnosis with plasma mcfDNA NGS enabled a faster clinical and laboratory diagnosis in 8 patients. Prompt diagnosis impacted antibiotic management in all 9 patients.
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Affiliation(s)
| | - Ahmed M Hamdi
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Todd M Lasco
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
- Baylor St. Luke's Medical Center, Houston, TX, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Baylor St. Luke's Medical Center, Houston, TX, USA
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6
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Daher M, Iordanov R, Al Mohajer M, Sohail MR, Staggers KA, Hamdi AM. Clinical utility of metagenomic next-generation sequencing in fever of undetermined origin. Ther Adv Infect Dis 2024; 11:20499361241244969. [PMID: 38645300 PMCID: PMC11027448 DOI: 10.1177/20499361241244969] [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: 01/07/2024] [Accepted: 03/18/2024] [Indexed: 04/23/2024] Open
Abstract
Background Metagenomic next-generation sequencing (mNGS) is a novel diagnostic tool increasingly used in the field of infectious diseases. Little guidance is available regarding its appropriate use in different patient populations and clinical syndromes. We aimed to review the clinical utility of mNGS in patients with a specific clinical syndrome and identify factors that may increase its utility. Methods We retrospectively reviewed charts of 72 non-immunocompromised adults hospitalized with the clinical syndrome of 'fever of undetermined origin' and underwent mNGS testing. Standardized criteria from a previously published study were used to determine the clinical impact of mNGS testing. We applied logistic regression to identify factors associated with a positive clinical impact. Results Of the 72 patients identified, 62.5% were males with a median age of 56. All patients had a fever at the time of evaluation. At least one organism was identified in 65.3% of cases; most commonly were Epstein-Barr virus (13.9%), cytomegalovirus (12.5%), and Rickettsia typhi (11.1%). Of those determined to have an infectious etiology of their febrile syndrome, 89.5% (n = 34/38) had a positive mNGS. Consistency between the organism(s) on mNGS and the clinically determined infectious etiology was 82.4%. mNGS had a positive clinical impact in 40.3% of cases, a negative impact in 2.8%, and no impact in 56.9% of cases. Besides age, we did not identify other factors associated with a higher likelihood of positive clinical impact. Conclusion In our review, mNGS had a positive clinical impact in a large proportion of adults with fever of undetermined origin, with minimal negative impact. However, mNGS results should be interpreted carefully given the high rate of detection of pathogens of unclear clinical significance. Randomized clinical trials are needed to assess the clinical utility of this novel diagnostic tool.
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Affiliation(s)
- Marilyne Daher
- Department of Internal Medicine, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Roumen Iordanov
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Baylor St. Luke’s Medical Center, Houston, TX, USA
| | - M. Rizwan Sohail
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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7
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Ku TSN, Al Mohajer M, Newton JA, Wilson MH, Monsees E, Hayden MK, Messacar K, Kisgen JJ, Diekema DJ, Morgan DJ, Sifri CD, Vaughn VM. Improving antimicrobial use through better diagnosis: The relationship between diagnostic stewardship and antimicrobial stewardship. Infect Control Hosp Epidemiol 2023; 44:1901-1908. [PMID: 37665212 DOI: 10.1017/ice.2023.156] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Antimicrobial stewardship programs (ASPs) exist to optimize antibiotic use, reduce selection for antimicrobial-resistant microorganisms, and improve patient outcomes. Rapid and accurate diagnosis is essential to optimal antibiotic use. Because diagnostic testing plays a significant role in diagnosing patients, it has one of the strongest influences on clinician antibiotic prescribing behaviors. Diagnostic stewardship, consequently, has emerged to improve clinician diagnostic testing and test result interpretation. Antimicrobial stewardship and diagnostic stewardship share common goals and are synergistic when used together. Although ASP requires a relationship with clinicians and focuses on person-to-person communication, diagnostic stewardship centers on a relationship with the laboratory and hardwiring testing changes into laboratory processes and the electronic health record. Here, we discuss how diagnostic stewardship can optimize the "Four Moments of Antibiotic Decision Making" created by the Agency for Healthcare Research and Quality and work synergistically with ASPs.
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Affiliation(s)
- Tsun Sheng N Ku
- Billings Clinic, Billings, Montana
- Rocky Vista University Montana College of Osteopathic Medicine, Billings, Montana
| | - Mayar Al Mohajer
- Section of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
- Infectious Diseases Section, Baylor St. Luke's Medical Center, Houston, Texas
- Infection Prevention, Diagnostic Stewardship and Antibiotic Stewardship, CommonSpirit Health Texas Division, Houston, Texas
| | - James A Newton
- Department of Antibiotic Stewardship, Washington Regional Medical Center, Fayetteville, Arkansas
| | - Marie H Wilson
- Infection Prevention & Control, Fred Hutchinson Cancer Center, Seattle, Washington
| | - Elizabeth Monsees
- Performance Excellence, Children's Mercy Hospital, Kansas City, Missouri
- University of Missouri School of Medicine, Kansas City, Missouri
| | - Mary K Hayden
- Division of Infectious Diseases, Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois
| | - Kevin Messacar
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado/Children's Hospital Colorado, Aurora, Colorado
| | | | - Daniel J Diekema
- Division of Infectious Diseases, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
- Maine Medical Center, Portland, Maine
| | - Daniel J Morgan
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland
- VA Maryland Healthcare System, Baltimore, Maryland
| | - Costi D Sifri
- University of Virginia School of Medicine, Charlottesville, Virginia
| | - Valerie M Vaughn
- Division of General Internal Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, Utah
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Al Mohajer M. Understanding the Gap Between Nursing Workforce in the United States and Population Needs-A Policy Brief. Avicenna J Med 2023; 13:206-214. [PMID: 38144915 PMCID: PMC10736185 DOI: 10.1055/s-0043-1775724] [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] [Indexed: 12/26/2023] Open
Abstract
Purpose This report is intended to analyze the root causes for the current gap between the nursing workforce and population needs in the United States. It aims to consolidate what is known about these contributing reasons and provide evidence-based recommendations for action. Methods The report utilized the Sample, Phenomenon of Interest, Design, Evaluation, Research type framework to develop the research question and the 5 Whys methodology for the root cause analysis. Results This report highlighted six major causative problems, including workforce market mismatch, poor financing design, inadequate governance, flawed technologies, insufficient research, and suboptimal service delivery. A detailed evaluation of root causes with supported evidence is presented. Conclusion The report provided seven actionable recommendations based on the analysis: (1) strengthening the nursing role in advancing equity, (2) investing in nursing well-being, (3) changing policies and payment structure, (4) including nursing in technology design, (5) strengthening nursing education, (6) developing a robust public health emergencies preparedness plan, and (7) investing in relevant research.
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Affiliation(s)
- Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, Texas, United States
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9
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Kelly GA, Iordanov R, Franklin A, Ahmed A, Srinivasan K, Hayon J, Lasco T, Amini R, Shay S, Kulkarni PA, Al Mohajer M. Impact of gastrointestinal polymerase chain reaction panels on antibiotic utilization in hospitalized adult patients. Antimicrob Steward Healthc Epidemiol 2023; 3:e135. [PMID: 37592964 PMCID: PMC10428147 DOI: 10.1017/ash.2023.174] [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] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 04/03/2023] [Accepted: 04/05/2023] [Indexed: 08/19/2023]
Abstract
Multiplex stool polymerase chain reaction (PCR) panels offer rapid comprehensive testing for patients with infectious diarrhea. We compared antibiotic utilization among hospitalized patients with suspected infectious diarrhea who underwent diagnostic testing with either a stool culture or stool PCR panel. No significant differences in antibiotic utilization were identified.
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Affiliation(s)
- Gillean A. Kelly
- Baylor College of Medicine, School of Medicine, Houston, Texas
- University of Texas Health Science Center at Houston, School of Public Health, Houston, Texas
| | - Roumen Iordanov
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, Texas
| | - Alex Franklin
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, Texas
| | - Amna Ahmed
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, Texas
| | - Krithika Srinivasan
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, Texas
| | - Jesica Hayon
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, Texas
| | - Todd Lasco
- Baylor College of Medicine, Department of Pathology & Immunology, Houston, Texas
| | - Rosie Amini
- Premier Inc., Department of Clinical Intelligence, Charlotte, North Carolina
| | - Sabra Shay
- Premier Inc., Department of Clinical Intelligence, Charlotte, North Carolina
| | - Prathit A. Kulkarni
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, Texas
- Michael E. DeBakey Veterans Affairs Medical Center, Medical Care Line, Houston, Texas
| | - Mayar Al Mohajer
- Baylor College of Medicine, Department of Medicine, Section of Infectious Diseases, Houston, Texas
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Al Mohajer M. Designing a Local Policy to Reduce HIV in Mexico City. Avicenna J Med 2023; 13:187-191. [PMID: 37799182 PMCID: PMC10550362 DOI: 10.1055/s-0043-1773791] [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] [Indexed: 10/07/2023] Open
Abstract
The Joint United Nations Program on human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (Joint United Nations Program on HIV/AIDS, UNAIDS) has recommended 90-90-90 goals to increase the number of patients who are aware of their status, on antiretroviral therapy, and have undetectable viral loads. Mexico City has made several achievements to aid in prevention, early diagnosis, and treatment; however, the incidence of HIV has not decreased over the past decade. This article reviews global initiatives that were successful in achieving some or all these metrics and provide a road map for Mexico to reach the desired goals.
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Affiliation(s)
- Mayar Al Mohajer
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States
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11
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Al Mohajer M, Lasco T. The Impact of Initial Specimen Diversion Systems on Blood Culture Contamination. Open Forum Infect Dis 2023; 10:ofad182. [PMID: 37152189 PMCID: PMC10157757 DOI: 10.1093/ofid/ofad182] [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] [Received: 01/01/2023] [Accepted: 04/04/2023] [Indexed: 04/08/2023] Open
Abstract
Abstract
Blood culture contamination is associated with increased antimicrobial use, length of stay, and hospital cost. To address this problem, blood culture diversion has been developed as an additional measure to reduce contamination to targeted goals. Three different versions were proposed, including an open technique and two commercially available devices. This study aims to review the existing literature and analyze evidence for these three techniques.
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Affiliation(s)
- Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine , Houston, TX , USA
| | - Todd Lasco
- Department of Pathology, Baylor College of Medicine , Houston, TX , USA
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12
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Brehm T, Al Mohajer M, Lasco TM. 329. Bedside Inoculation of Blood Culture Bottles Does Not Improve Ascites Culture Positivity Rate in Spontaneous Bacterial Peritonitis. Open Forum Infect Dis 2022. [PMCID: PMC9752865 DOI: 10.1093/ofid/ofac492.407] [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
Background Prior research demonstrates increased positivity rate for ascites cultures in spontaneous bacterial peritonitis (SBP) when directly inoculated into blood culture bottles at bedside, versus the “conventional method” - transportation of ascitic fluid in a sealed syringe to the laboratory, centrifuging, and plating on Chocolate, Blood, and MacConkey’s agars and in a Schaedler broth. We hypothesized that collection of ascites via direct inoculation into blood culture bottles would improve ascites culture positivity rate in SBP when compared to prior methods. Methods In November of 2021, our institution implemented a policy in which all ascites cultures were directly inoculated into blood culture bottles at bedside. We retrospectively reviewed all ascites cultures collected from May of 2021 through April of 2022, including all cultures with an absolute neutrophil count of greater than 250 cells/mm3. We excluded all samples from patients with secondary bacterial peritonitis and all samples collected in November. If a patient had multiple samples that met inclusion criteria, only the first was included for analysis. Our primary outcome was positivity rate of cultures pre- and post-implementation of this new policy. Results 1375 ascites cultures were collected. Of these, 52 met our inclusion criteria. These patients were on average 58 years old (range 33-74), 50% female, with a median MELD of 25.5 (range 8-40). The conventional method was positive in 7/37 (18.9%) cultures, and direct inoculation of blood cultures in 1/15 (6.67%), p = .27. Conclusion As opposed to the previous literature, we detected no difference in positivity rate between the conventional method of ascites culture compared to direct inoculation of blood cultures at the bedside. This difference from prior literature may be due to differences in time to inoculation, our smaller sample size, or overfilling of the bottles during inoculation. Disclosures All Authors: No reported disclosures.
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13
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Kelly G, Iordanov R, Franklin A, Ahmed A, Srinivasan K, Hayon J, Lasco TM, Amini R, Shay S, Kulkarni PA, Mohajer MA. 185. Implementation of Multiplex Polymerase Chain Reaction in Clinical Practice: Impact on Antimicrobial Management In Infectious Diarrhea. Open Forum Infect Dis 2022. [PMCID: PMC9751986 DOI: 10.1093/ofid/ofac492.263] [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 Stool culture and stool polymerase chain reaction (PCR) panels are both used to evaluate patients with suspected infectious diarrhea. Stool PCR panels are especially advantageous because of their ability to detect a broad array of infectious pathogens in less than one hour. Our study assessed how the use of stool PCR panels instead of stool culture impacted antibiotic days of therapy (DOT) and length of therapy (LOT) in hospitalized patients with suspected infectious diarrhea. Methods In December 2021, an intervention was implemented in our hospital in which all electronic orders for stool cultures were automatically switched to stool PCR testing. The pre-intervention group was comprised of 75 hospitalized adult patients who had a stool culture obtained from September to November 2021. The post-intervention group was comprised of 81 adult patients who had a stool PCR obtained from December 2021 to February 2022. The DOT and LOT for antibiotics prescribed specifically for infectious diarrhea were determined for each patient; DOT and LOT were compared between the pre- and post- intervention groups. Results The median DOT in the pre- and post-intervention groups was 0 with a range of 0-10 and 0-8, respectively. The median LOT in the pre- and post-intervention groups was 0 (range 0-5 for both groups). No significant difference in the median DOT (Wilcoxon rank sum test, p-value = 0.967) or LOT (Wilcoxon rank sum test, p-value = 0.993) was found between the pre- and post-intervention groups (Figure 1). After adjusting for patient days present, no significant change in DOT or LOT incidence rate was found between the pre- and post-intervention groups. The DOT incidence rate ratio (RR) was 0.71 (95% CI 0.42, 1.22), and the LOT incidence RR was 0.67 (95% CI 0.36, 1.24).
DOT and LOT Comparisons between Pre- and Post-Intervention Groups ![]() Antibiotic days of therapy (DOT) stratified by study period (top) and antibiotic (LOT) stratified by study period (bottom). Conclusion An intervention of automatically changing stool culture testing to stool PCR testing did not result in a significant change in median DOT or LOT in hospitalized adult patients, nor did it result in a significant change in DOT or LOT incidence rate. These findings could be explained by an insufficient sample size (n = 156), limiting the study’s power. Additionally, most patients in the pre-intervention group received no antibiotics for infectious diarrhea, resulting in a short DOT and LOT at baseline. Disclosures Sabra Shay, BSN, MPH, Premier Inc.: Employee Prathit A. Kulkarni, M.D., Vessel Health, Inc.: Grant/Research Support.
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Affiliation(s)
- Gillean Kelly
- Baylor College of Medicine / The University of Texas Health Science Center at Houston School of Public Health, Houston, Texas
| | | | | | - Amna Ahmed
- Baylor College of Medicine, Houston, Texas
| | | | | | - Todd M Lasco
- Baylor St. Luke's Medical Center, Houston, Texas
| | - Rosie Amini
- Premier Healthcare Inc., Seattle, Washington
| | | | - Prathit A Kulkarni
- Michael E. DeBakey VA Medical Center / Baylor College of Medicine, Houston, Texas
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Figg WD, Crawford DL, Taylor TN, Al Mohajer M. Rare Diagnostic and Clinical Manifestations in an Acute Hepatitis A Infection: A Case Report. Cureus 2022; 14:e29194. [PMID: 36258990 PMCID: PMC9572876 DOI: 10.7759/cureus.29194] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 11/18/2022] Open
Abstract
The hepatitis A virus (HAV) is a common cause of infectious hepatitis worldwide. In adults, clinical manifestations typically involve fever, nausea/vomiting, fatigue, abdominal pain, and jaundice, although rarer manifestations may be observed. Acute hepatitis A infection is detected via anti-HAV IgM antibodies, which are present in almost all patients at symptom onset. In this case, we present a patient who not only tested negative for acute HAV infection at symptom onset, but also presented with uncommon, extrahepatic manifestations including maculopapular skin rash and polyarthralgia. Wariness of such a presentation can facilitate the timely diagnosis of atypical cases of HAV infection. We report the case of a 51-year-old man who presented with fever, abdominal pain, headaches, and diarrhea for one week with elevated liver enzymes and leukocytosis. Workup consisting of viral hepatitis panels, various infectious studies, and rheumatologic antibody titers did not initially reveal an etiology for the patient’s presentation. Computed tomography (CT) abdomen and pelvis, abdominal ultrasound, magnetic resonance cholangiopancreatography (MRCP), and hepatobiliary iminodiacetic acid (HIDA) scan did not reveal acute pathology. The patient’s symptoms worsened over the following days, and he additionally developed bilateral wrist pain, digital arthralgias, paraspinal back pain, diffuse muscular weakness, and a pruritic maculopapular rash affecting the flanks and extremities. Eventually, viral hepatitis studies were repeated which revealed elevated levels of anti-HAV IgM antibodies, indicating acute hepatitis A infection. The patient was treated supportively while hospitalized with subsequent improvement of symptoms and lab abnormalities. Since discharge, the patient had not experienced persistent sequelae of the disease. This case of acute viral hepatitis A infection is notable for two reasons: (1) the patient experienced uncommon, delayed, extrahepatic manifestations of disease, and (2) the initial viral hepatitis studies revealed undetectable anti-HAV IgM levels despite having experienced symptoms of illness for several days. This case suggests that repeat viral hepatitis testing may be warranted in patients who continue to experience manifestations of the infection after initially testing negative. It also emphasizes the importance of recognizing potential atypical manifestations of acute hepatitis A infection.
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15
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Goyal RK, Moffett BS, Gobburu JVS, Al Mohajer M. Population Pharmacokinetics of Vancomycin in Pregnant Women. Front Pharmacol 2022; 13:873439. [PMID: 35734401 PMCID: PMC9207242 DOI: 10.3389/fphar.2022.873439] [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: 02/10/2022] [Accepted: 05/23/2022] [Indexed: 11/22/2022] Open
Abstract
Objective: Vancomycin is a glycopeptide antibacterial indicated for serious gram-positive infections. Pharmacokinetics (PK) of vancomycin have not been described in pregnant women. This study aims to characterize the PK disposition of vancomycin in pregnant women based on data acquired from a database of routine hospital care for therapeutic drug monitoring to better inform dosing decisions. Methods: In this study, plasma drug concentration data from 34 pregnant hospitalized women who were administered intravenous vancomycin was analyzed. A population pharmacokinetic (PPK) model was developed using non-linear mixed effects modeling. Model selection was based on statistical criterion, graphical analysis, and physiologic relevance. Using the final model AUC0-24 (PK efficacy index of vancomycin) was compared with non-pregnant population. Results: Vancomycin PK in pregnant women were best described by a two-compartment model with first-order elimination and the following parameters: clearance (inter individual variability) of 7.64 L/hr (32%), central volume of 67.35 L, inter-compartmental clearance of 9.06 L/h, and peripheral volume of 37.5 L in a typical patient with 175 ml/min creatinine clearance (CRCL) and 45 kg fat-free mass (FFM). The calculated geometric mean of AUC0-24 for the pregnant population was 223 ug.h/ ml and 226 ug.h/ ml for the non-pregnant population. Conclusion: Our analysis suggests that vancomycin PK in pregnant women is consistent with non-pregnant adults and the dosing regimens used for non-pregnant patients may also be applicable to pregnant patients.
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Affiliation(s)
| | - Brady S. Moffett
- Texas Children’s Hospital, Houston, TX, United States
- Baylor College of Medicine, Houston, TX, United States
| | - Jogarao V. S. Gobburu
- University of Maryland, Baltimore, MD, United States
- *Correspondence: Jogarao V. S. Gobburu,
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16
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Godwin KM, Horstman MJ, Chao S, Dolansky M, Al Mohajer M, Naik AD. Developing an Interprofessional Health Care Improvement Portfolio: Results From a Consensus Panel Process. Acad Med 2022; 97:503-509. [PMID: 34647921 DOI: 10.1097/acm.0000000000004448] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
The increased focus on professional-led, continuous health care improvement has not produced formalized processes for identifying, recognizing, and rewarding excellence in quality improvement. Moreover, the team-based nature of improvement requires a mechanism to document interprofessional contributions. In 2018, the authors created a health care improvement portfolio to document and demonstrate individual impact for the purpose of promotion. A draft portfolio was developed from a review of the literature and publicly available quality improvement and educational portfolios. The portfolio was further refined through a 2-round, modified Delphi consensus process with a panel of interprofessional experts across North America. In the first round, 35 panelists gave feedback through open-ended comments on the design and content of the portfolio. In the second round, 34 panelists rated the comprehensiveness and clarity of the portfolio on a scale of 1-9 (1 = lowest, 9 = highest) and provided comments. Consensus was defined as an average score over 8.0. Panelists in the second round achieved consensus, with average scores of 8.4 in comprehensiveness and 8.3 in clarity (range, 6-9). The finalized portfolio includes the following sections: personal statement; health care improvement training and certification; leadership and administrative roles; health care improvement project activities; health care improvement coaching, teaching, and curricular activities; health care improvement honors, awards, and recognitions; and supporting documents. The portfolio facilitates the documentation of health care professionals' contributions to and impact in health care improvement and covers the breadth of interprofessional health care improvement (i.e., projects, leadership, education, scholarship). The portfolio can be tailored to an individual's area of specific expertise. While this portfolio was originally developed for interprofessional faculty at academic institutions, the content and structure of the portfolio are easily adapted for health care providers in other health care settings.
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Affiliation(s)
- Kyler M Godwin
- K.M. Godwin is investigator, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Department of Veterans Affairs (VA) Medical Center, director, VA Quality Scholars Coordinating Center, and assistant professor, Department of Medicine, Baylor College of Medicine, Houston, Texas; ORCID: https://orcid.org/0000-0002-6286-1899
| | - Molly J Horstman
- M.J. Horstman is investigator, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Department of Veterans Affairs (VA) Medical Center, core faculty, VA Quality Scholars Coordinating Center, and assistant professor, Department of Medicine, Baylor College of Medicine, Houston, Texas; ORCID: https://orcid.org/0000-0003-3936-8112
| | - Samantha Chao
- S. Chao is a Health, Humanism, and Society Scholars Program undergraduate student, Rice University, Houston, Texas
| | - Mary Dolansky
- M. Dolansky is Sarah C. Hirsh professor and director, Quality and Safety Education for Nurses Institute, Frances Payne Bolton School of Nursing, and associate professor, Department of Population and Quantitative Health Sciences, Case Western Reserve School of Medicine, Cleveland, Ohio, and senior advisor, VA Quality Scholars program; ORCID: https://orcid.org/000-0002-6472-1275
| | - Mayar Al Mohajer
- M. Al Mohajer is associate professor, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Aanand D Naik
- A.D. Naik is investigator, Center for Innovations in Quality, Effectiveness, and Safety, Michael E. DeBakey Department of Veterans Affairs (VA) Medical Center, senior advisor, VA Quality Scholars program, and professor and Luchi Chair in geriatric medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas; https://orcid.org/0000-0001-6936-7984
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17
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Petrova E, Farinholt T, Joshi TP, Moreno H, Al Mohajer M, Patel SM, Petrosino J, Anandasabapathy S. A Community-Based Management of COVID-19 in a Mobile Container Unit. Vaccines (Basel) 2021; 9:1362. [PMID: 34835293 PMCID: PMC8624920 DOI: 10.3390/vaccines9111362] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Revised: 11/14/2021] [Accepted: 11/16/2021] [Indexed: 11/30/2022] Open
Abstract
Vaccine uptake is a multifactor measure of successful immunization outcomes that includes access to healthcare and vaccine hesitancy for both healthcare workers and communities. The present coronavirus disease (COVID-19) pandemic has highlighted the need for novel strategies to expand vaccine coverage in underserved regions. Mobile clinics hold the promise of ameliorating such inequities, although there is a paucity of studies that validate environmental infection in such facilities. Here, we describe community-based management of COVID-19 through a Smart Pod mobile clinic deployed in an underserved community area in the United States (Aldine, Harris County, TX, USA). In particular, we validate infection control and biological decontamination of the Smart Pod by testing surfaces and the air-filtration system for the COVID-19 virus and bacterial pathogens. We show the Smart Pod to be efficacious in providing a safe clinical environment for vaccine delivery. Moreover, in the Smart Pod, up-to-date education of community healthcare workers was provided to reduce vaccine hesitancy and improve COVID-19 vaccine uptake. The proposed solution has the potential to augment existing hospital capacity and combat the COVID-19 pandemic locally and globally.
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Affiliation(s)
- Elena Petrova
- Baylor Global Health, Baylor College of Medicine, Houston, TX 77030, USA;
- Department of Medicine—Gastroenterology, Baylor College of Medicine, Houston, TX 77030, USA
| | - Timothy Farinholt
- Alkek Center for Metagenomics and Microbiome Research, Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA; (T.F.); (H.M.); (J.P.)
| | - Tejas P. Joshi
- Baylor Global Health, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Hannah Moreno
- Alkek Center for Metagenomics and Microbiome Research, Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA; (T.F.); (H.M.); (J.P.)
| | - Mayar Al Mohajer
- Department of Medicine—Infectious Disease, Baylor College of Medicine, Houston, TX 77030, USA; (M.A.M.); (S.M.P.)
| | - Shital M. Patel
- Department of Medicine—Infectious Disease, Baylor College of Medicine, Houston, TX 77030, USA; (M.A.M.); (S.M.P.)
| | - Joseph Petrosino
- Alkek Center for Metagenomics and Microbiome Research, Molecular Virology and Microbiology, Baylor College of Medicine, Houston, TX 77030, USA; (T.F.); (H.M.); (J.P.)
| | - Sharmila Anandasabapathy
- Baylor Global Health, Baylor College of Medicine, Houston, TX 77030, USA;
- Department of Medicine—Gastroenterology, Baylor College of Medicine, Houston, TX 77030, USA
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18
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Al Mohajer M, Wermuth PP, Wendt R. Genital Herpes Disclosure Attitudes Among Men Who Have Sex with Men. Arch Sex Behav 2021; 50:3323-3328. [PMID: 34671875 DOI: 10.1007/s10508-021-01971-4] [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: 09/01/2020] [Revised: 02/22/2021] [Accepted: 02/24/2021] [Indexed: 06/13/2023]
Abstract
An abundance of literature interested in sexually transmitted infections-related disclosure attitudes among MSM (men who have sex with men) exists. However, comparatively few studies have examined these with respect to genital herpes. This cross-sectional study examined attitudes about herpes-related disclosure among Houston MSM. Convenience sampling at Houston-based MSM venues and events was conducted during December 2018 and January 2019 with 302 participants recruited. Participants were asked if an individual with genital herpes should disclose to others and if they would disclose to others if they had/have genital herpes. Factors associated with decreased belief that someone should disclose a genital herpes infection to others were history of genital herpes (OR 0.14, 95% CI [0.04, 0.55]) and race other than white, black, or Hispanic/Latino (OR 0.34, 95% CI [0.15, 0.77]). History of 0 to 1 sexual partner(s) in the past year was associated with increased belief that an individual should disclose (OR 2.43, 95% CI [1.19, 4.98]), while self-reported history of genital herpes was associated with decreased intent to disclose one's own infection to potential partners (OR 0.30, 95% CI [0.10, 0.91]). Self-reported history of genital herpes was associated with decreased belief that someone with genital herpes should tell others and with decreased likelihood to disclose one's own status. Lastly, race other than white, black, or Hispanic/Latino was associated with increased belief that someone with genital herpes should not tell others. Normalization of genital herpes could bolster intent to disclose genital herpes infection and improve sexual outcomes.
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Affiliation(s)
- Mayar Al Mohajer
- Infectious Diseases, Baylor College of Medicine, Houston, TX, USA
| | - Paige Padgett Wermuth
- Department of Management, Policy, and Community Health, University of Texas School of Public Health, 1200 Pressler St., Houston, TX, 77030, USA
| | - Russell Wendt
- Department of Management, Policy, and Community Health, University of Texas School of Public Health, 1200 Pressler St., Houston, TX, 77030, USA.
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19
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Beatty N, August J, Saenz JA, Nix DE, Matthias KR, Mohajer MA. Knowledge, attitude, and practices associated with the diagnosis and management of skin and soft-tissue infections among medical students, residents, and attending physicians. Avicenna J Med 2021; 8:104-106. [PMID: 30090749 PMCID: PMC6057159 DOI: 10.4103/ajm.ajm_200_17] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Skin and soft-tissue infections (SSTIs) are commonly encountered by medical students, residents, and trainees. The Infectious Diseases Society of America (IDSA) has updated its recommendations regarding SSTI diagnosis and management in June 2014. We assessed knowledge, attitude, and practices toward diagnosis and management of SSTIs using an online survey. We disseminated the survey to medical students, residents, and attending physicians practicing in family and internal medicine department at a university-based hospital. A total of 103 surveys were completed out of 121 sent (85.1%) between July 2015 and March 2016. There were nine medical questions in the survey. The mean of correct answers was 4.5/9 ± 2.0. Medical knowledge correlated with the level of education (P < 0.001) but not with subspecialty (P = 0.97). Around 35% were familiar with the updated IDSA guidelines pertaining to SSTIs. The majority (85%) responded that the hospital staff would benefit from additional training and 75% agreed that more antibiotic stewardship education is needed. Our study shows that there are significant opportunities for development among students and physicians who encounter SSTIs.
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Affiliation(s)
- Norman Beatty
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Jessica August
- Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Joe Anthony Saenz
- Department of Family and Community Medicine, University of Arizona, Tucson, AZ, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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20
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Abstract
The significance of bacteriuria in patients with end-stage renal disease (ESRD) on hemodialysis (HD) is unclear. It is not known whether treatment of asymptomatic bacteriuria is associated with lower rates of urinary tract infection or readmission. Adult patients with ESRD on HD were retrospectively evaluated to assess factors associated with the recurrence of bacteriuria and readmission. We included 68 patients in the analysis. There were 20 patients (29.4%) with urinary symptoms. All symptomatic patients received antibiotic therapy, whereas half of the asymptomatic patients received antibiotics. Antibiotic use was not associated with lower rates of readmission or the recurrence of bacteriuria.
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Affiliation(s)
- Ibrahim Taweel
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Norman Beatty
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Alexsis Duarte
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - David Nix
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA.,Department of Pharmacy Practice and Science, University of Arizona, Tucson, AZ, USA
| | - Kathryn Matthias
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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21
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Centeno FH, Lasco T, Ahmed AA, Al Mohajer M. Characteristics of Rickettsia typhi Infections Detected with Next-Generation Sequencing of Microbial Cell-Free Deoxyribonucleic Acid in a Tertiary Care Hospital. Open Forum Infect Dis 2021; 8:ofab147. [PMID: 34250186 PMCID: PMC8266567 DOI: 10.1093/ofid/ofab147] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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: 01/21/2021] [Accepted: 03/23/2021] [Indexed: 11/13/2022] Open
Abstract
We present 10 patients with Rickettsia typhi infection in whom next-generation sequencing of microbial cell-free deoxyribonucleic acid (mcfDNA) was used as a diagnostic tool. Rickettsia typhi mcfDNA was detected in all cases and was more rapid and specific than rickettsial serology. Rickettsia typhi mcfDNA impacted antibiotic management in 50% of patients.
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Affiliation(s)
| | - Todd Lasco
- Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas, USA.,Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Asim A Ahmed
- Medical Affairs, Karius, Redwood City, California, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, Texas, USA.,Baylor St. Luke's Medical Center, Houston, Texas, USA
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22
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Al Mohajer M, Panthagani KM, Lasco T, Lembcke B, Hemmige V. Association between universal face shield in a quaternary care center and reduction of SARS-COV2 infections among healthcare personnel and hospitalized patients. Int J Infect Dis 2021; 105:252-255. [PMID: 33610788 PMCID: PMC7891045 DOI: 10.1016/j.ijid.2021.02.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 01/11/2021] [Revised: 02/11/2021] [Accepted: 02/15/2021] [Indexed: 12/13/2022] Open
Abstract
We implemented universal face shield use for all healthcare personnel upon entry to facility in order to counter an increase in SARS-COV2 cases among healthcare personnel and hospitalized patients. There was a marked reduction of infections in both healthcare personnel and hospitalized patients between pre and post intervention. Our results support universal face shield use as part of a multifaceted approach in areas of high SARS-COV2 community transmission.
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Affiliation(s)
- Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA; Baylor St. Luke's Medical Center, Houston, TX, USA.
| | | | - Todd Lasco
- Baylor St. Luke's Medical Center, Houston, TX, USA; Department of Pathology and Immunology, Baylor College of Medicine, Houston, TX, USA
| | | | - Vagish Hemmige
- Montefiore Medical Center, Bronx, NY, USA; Albert Einstein College of Medicine, Bronx, NY, USA
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23
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Wang EW, Weekley A, McCarty J, Koo H, Lembcke B, Al Mohajer M. Impact of a division-wide bundle on hospital-acquired Clostridioides difficile cases, antibiotic days of therapy, testing appropriateness, and associated financial costs. Avicenna J Med 2021; 11:27-32. [PMID: 33520786 PMCID: PMC7839267 DOI: 10.4103/ajm.ajm_193_19] [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] [Indexed: 11/08/2022] Open
Abstract
Introduction: Updated international guidelines recommend the use of a two-step algorithm (glutamate dehydrogenase [GDH] or nucleic-acid amplification test [NAAT] plus toxin) rather than NAAT alone for the diagnosis of Clostridioides difficile (formerly Clostridium difficile) infections. The goal of our project was to evaluate the impact of a new bundle on the rate of hospital-acquired C. difficile infections (CDIs), hospital-acquired CDI standardized infection ratio (SIR), antibiotic days of therapy (DOT), and financial cost. Materials and Methods: The new bundle was implemented in April 2018. This bundle was implemented across five hospitals in Catholic Health Initiatives (CHI) Texas Division. The bundle included a switch from NAAT to a two-step process (GDH and toxin). We placed the new test in an order panel which included enteric isolation and required indications for C. difficile testing. We used quarterly data pre- and post-intervention to calculate SIR and DOT. Results: In the pre-intervention period, 15.5% of the total 3513 C. difficile NAAT was positive. In the post-intervention period, 5.7% of a total of 2845 GDH and toxin assays was positive for both GDH and toxin (P < 0.0001). SIR, which adjusts for denominator and change in testing methodology, also dropped from 1.02 to 0.43. The estimated cost associated with positive C. difficile cases dropped from 1,932,150 USD to 1,113,800 USD with an estimated yearly cost saving of 794,150 USD. Compliance with enteric isolation improved from 73.1% to 92.5% (P = 0.008). Conclusion: The new testing bundle led to a marked reduction in hospital-acquired CDI and unnecessary treatment, reduction in C. difficile testing, an increase in compliance with enteric isolation, and significant cost savings.
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Affiliation(s)
- Elizabeth Wenqian Wang
- Department of Infectious Diseases, Infection Control and Employee Health, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA.,Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Ashlee Weekley
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Jennifer McCarty
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Hoonmo Koo
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Bradley Lembcke
- Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
| | - Mayar Al Mohajer
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA.,Department of Infection Prevention & Control, CHI Baylor St. Luke's Medical Center, Houston, Texas, USA
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24
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Francisco DMA, Woc-colburn L, Carlson TJ, Lasco T, Barrett MB, Mohajer MA. 680. The Use of Plasma Next-Generation Sequencing Test in the Management of Immunocompetent and Immunocompromised Patients – A Single Center Retrospective Study. Open Forum Infect Dis 2020. [PMCID: PMC7777907 DOI: 10.1093/ofid/ofaa439.872] [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] [Indexed: 11/17/2022] Open
Abstract
Background Microbiological culture data is a longstanding gold standard in diagnostics. Unfortunately, yield from cultures have been inconsistent and slow, prompting the need for newer tests including the plasma-based next-generation sequencing (NGS) tool. This study aims to describe the use of NGS and the corresponding change in management. Methods A descriptive retrospective study was done on hospitalized adults at CHI-Baylor St. Luke’s in Houston, Texas with NGS tests from Jan 1, 2017 to Dec 31, 2018. Graph 1 - Next Generation Sequencing Test Breakdown ![]()
Results There were 167 NGS tests performed. Most patients were non-Hispanic (n=129) Caucasian (n=106) males (n=116) with a mean age of 52. Furthermore, 61 were immunocompromised patients [solid organ transplant (n=30), HIV-AIDS (n=14) and rheumatology patients on immunosuppression (n=12)]. During the study, the hospital staff prepared a list of indications for NGS testing including: systemic or deep seated infection where a biopsy or other workup is negative or not possible (n=50), fever of unknown origin (n=26), culture negative endocarditis (n=15), HIV/AIDS with fever (n=10), transplant patient with fever (n=5). There were 60 cases where the indications were not on this list (36%). Results showed that 118/167 (71%) were positive. The most common organisms identified were gram-negative bacteria (54/118; 46%) followed by viruses (49/118; 42%), gram-positive bacteria (48/118; 41%), fungi (16/118; 14%), atypical bacteria (9/118; 8%), mycobacterium (4/118; 3%), and parasites (4/118; 3%). Blood cultures were concurrently obtained in 148/167 (89%) of the cases and returned negative in 137/148 (93%) of cases. In terms of change of management, the largest change was found in glycopeptide use (36 fewer patients after NGS results). Next was on anti-mycobacterial drugs where 27 were added among 8 instances. Only 36 patients were taken off antibiotics, even though 49 patients had negative results. In total, 120 out of 160 cases had antibiotic changes. Table 1 - Demographic and Laboratory Characteristics ![]()
Graph 2 - Change in Number of Antibiotics (Total: Before and After) ![]()
Graph 3 - Indications for Testing and Change in Number of Antibiotics ![]()
Conclusion We observed a large decrease in glycopeptide use after NGS results which suggests physicians’ comfort in withdrawing MRSA coverage. In addition, anti-mycobacterial coverage increased corresponding to early mycobacterial detection with NGS. This study highlights the importance of clinical judgement in the age of rapid diagnostics. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | - Travis J Carlson
- High Point University Fred Wilson School of Pharmacy, High Point, North Carolina
| | - Todd Lasco
- Baylor St. Luke’s Medical Center, The Woodlands, Texas
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25
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Abstract
Abstract
Background
Computer-based antibiotic time-outs, in which providers receive automated electronic medical record (EMR) alerts regarding continuation of inpatient antibiotics (Anb), are common stewardship initiatives. We assessed the efficacy of such an intervention in oncology patients (pts), who frequently receive Anb when hospitalized.
Methods
An EMR alert triggered 48 hours after starting vancomycin (vanc), cefepime (cef), piperacillin-tazobactam (pip-tazo), meropenem (mero), and fluoroquinolones (flq) was initiated in a tertiary care hospital in November 2018. To assess the efficacy of the intervention in adults with solid tumor malignancies, demographic, vital sign, laboratory, and treatment data were extracted retrospectively from the EMR. Pts with neutropenic fever, organ transplant, trauma, and cardiopulmonary arrest were excluded. We compared length of therapy [LOT; days of therapy per 1000 patient-days (DOT/1000 pd)] via t-test and incidence rate ratio (IRR) for 3- and 12-month periods preceding and following the intervention. November 2018 was excluded as a washout period.
Results
The groups did not differ by age, sex, length of stay, or rate of bacteremia (Table 1). Comparing the 3 months before and after the intervention, neither mean LOT (2.9 ± 0.20 vs 2.6 ± 0.14 DOT/1000 pd, p=0.31) nor rate of Anb use changed (IRR 0.97, p=0.32). However, when considering only the Anb targeted by the intervention, cef usage was 1.4 times higher post- intervention (p=0.002), while use of other Anb was similar (Table 2). Comparing 12 months before to 12 months after the intervention, mean LOT was longer after (0.74 ± 0.018) than before (0.68 ± 0.020 DOT/1000 pd; p=0.03), and Anb use increased (IRR 1.3, p< 0.0001). Specifically, mero (IRR 1.8, p< 0.0001) and cef (1.6, p< 0.0001) were used more frequently after the intervention while none were used less (table 2).
Table 1: Study Group Characteristics
Table 2: Antibiotic Use Three Months Before and After, and Twelve Months Before and After, the Intervention
Conclusion
Despite wide adoption and efficacy in other populations, an EMR-based Anb time-out did not mitigate the continuation of Anb among inpatients with solid tumors. The intervention may require additional measures, such as an active role for pharmacy, to be effective. However, qualitative studies may also be required to understand why providers are hesitant to limit Anb use in this population.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
- Jonathan M Hyak
- The Ohio State University Wexner Medical Center, GRANDVIEW, Ohio
| | - Mayar Al Mohajer
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center; Baylor College of Medicine, Houston, TX
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Clark E, Kulkarni P, Mohajer MA, Rose S, Serpa J, Singhal G, Giordano TG. 1129. Optimizing Feedback Strategies on the Infectious Diseases Inpatient Service. Open Forum Infect Dis 2020. [PMCID: PMC7776358 DOI: 10.1093/ofid/ofaa439.1315] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Timely, efficient, and effective feedback strategies are crucial for enhancing faculty-trainee communication and trainee education. Here we describe attitudes, practices, and perceived behaviors regarding giving feedback to medical trainees rotating on Infectious Diseases (ID) inpatient consult services. Methods An anonymous survey on feedback strategies was distributed to our adult ID Section in February 2020 as part of a facilitated discussion on optimizing trainee clinical education. Results Twenty-six ID Section members completed the survey (18 faculty, 8 trainees). Most trainees (62.5%) and faculty (66.7%) felt that trainees are “sometimes” comfortable voicing concerns to faculty; however, no trainees but 11.1% of faculty indicated that trainees are “always” comfortable voicing concerns to faculty. Most trainees (87.5%) felt that conversations about team expectations occur “sometimes” or “often.” In contrast, most faculty (72.2%) felt that these conversations “always” occur. Although most faculty felt that both informal (94.4%) and formal (83.3%) feedback should be given to trainees, 22.2% of faculty responded that they do not explicitly use the term “feedback” when discussing feedback with a trainee. No trainees and 22.2% of faculty indicated that they utilize a feedback tool. Regarding quantity of feedback trainees perceive they receive from faculty, 37.5% of trainees felt they needed more feedback while 50% felt they received adequate feedback. Most faculty (88.9%) responded that they encourage trainees to give feedback to faculty, although most trainees (62.5%) responded “sometimes” regarding how comfortable they feel doing so. Conclusion In summary, we found differences between faculty and trainees regarding two important aspects of medical education: setting expectations and providing feedback. While most faculty feel that conversations regarding these topics occur invariably, trainees do not always share this perception. Trainees felt less comfortable voicing concerns and giving feedback to faculty than faculty perceived them to be. Overall, the data suggest that there is room for improvement to ensure that trainees and faculty are operating from a shared mental model regarding setting team expectations and providing/receiving feedback. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Eva Clark
- Baylor College of Medicine, Houston, Texas
| | | | - Mayar Al Mohajer
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center; Baylor College of Medicine, Houston, TX
| | | | - Jose Serpa
- Baylor College of Medicine, Houston, Texas
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Hyak JM, Mohajer MA, Musher D, Musher B. 198. Clinical Prediction of Bacteremia and the Need for Early Antibiotic Therapy in Solid Tumor Cancer Patients. Open Forum Infect Dis 2020. [PMCID: PMC7778017 DOI: 10.1093/ofid/ofaa439.242] [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] [Indexed: 11/21/2022] Open
Abstract
Background Cancer patients (pts) frequently receive empiric antibiotics without clear indication. This retrospective study investigated the relationship between the systemic inflammatory response syndrome (SIRS), early antibiotic (Anb) use, and bacteremia in solid tumor pts presenting to the emergency department (ED). Methods We extracted data from the electronic medical records of adults with solid tumors admitted to a tertiary care hospital through the ED for any reason over a 2 year period. Pts with neutropenic fever, organ transplant, trauma, or cardiopulmonary arrest were excluded. Rates of SIRS and bacteremia among pts receiving early Anb (eAnb, within 8 hours of admission) were compared to all others using χ 2. Binomial regression and receiver operator curves assessed predictors of bacteremia. Results Of 3580 eligible pts, 1344 pts were SIRS positive (≥ 2 criteria) and 2236 were SIRS negative; 501 (37%) and 493 (22%), respectively, received eAnb (p< 0.001). eAnb use increased with additional SIRS criteria (Fig 1). Of SIRS positive pts, 860 (64%) had BCs drawn within 48 hrs of presentation, of which 19% were positive. Of SIRS negative pts, 826 (37%) had cultures drawn within 48 hrs of presentation, of which 14% were positive (19% vs 14%, p=0.004). Of pts who had BCs drawn, the proportion of positive BCs among those who received eAnb and those who did not was identical (16% in each group; p=1). Of 276 pts ultimately proven to have bacteremia within 48 hrs, only 59% were SIRS positive, and only 49% received eAnb in the ED. By regression, only two SIRS components predicted bacteremia, fever (OR 1.8 ± 0.39, p=0.01) and tachycardia (1.4 ± 0.22, p=0.03), and SIRS criteria as a whole were poorly predictive of bacteremia (AUC 0.57, Table 1). A more robust model, which included additional labs and vital signs, was only marginally better (AUC 0.61, Table 2). Figure 1: Proportion of patients receiving early antibiotics by SIRS score ![]()
Table 1: SIRS as a predictor of bacteremia ![]()
Table 2: Best predictive model of bacteremia ![]()
Conclusion Clinicians still use SIRS criteria to determine the need for eAnb. However, SIRS criteria are poor predictors of bacteremia in solid tumor pts, who frequently manifest them due to complications of cancer or cancer-directed therapy rather than infection. Furthermore, patients who are SIRS negative may be bacteremic. More reliable models are needed to guide judicious use of Anb in the solid tumor population. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Jonathan M Hyak
- The Ohio State University Wexner Medical Center, GRANDVIEW, Ohio
| | - Mayar Al Mohajer
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center; Baylor College of Medicine, Houston, TX
| | - Daniel Musher
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Mohajer MA, Pipkins T, Atmar R, Barradas MR, Young E, Giordano TG, Kulkarni P, Serpa J. 1122. Improving Knowledge of Infectious Disease Fellows Regarding Infection Prevention & Antibiotic Stewardship Using a Multi-Faceted Approach. Open Forum Infect Dis 2020. [PMCID: PMC7777347 DOI: 10.1093/ofid/ofaa439.1308] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background Infection prevention and antibiotic stewardship are critical to the safe and effective delivery of patient care. The primary objective of this fellowship rotation is to train infectious diseases fellows to develop key competencies in the fields of infection prevention and antibiotic stewardship. Methods We implemented an infection prevention and antibiotic stewardship rotation for the first-year infectious disease fellows starting July 2017. This new one-month rotation included several lectures by infectious diseases physicians, infection preventionists and pharmacists. Fellows rounded with infection preventionists (isolation, device, environmental, and endoscopy rounds) and participated in infection control subcommittees (CLABSI, CAUTI, Clostridioides difficile colitis and surgical site infections). Fellows were required to present infection control data and develop a proposal for a quality improvement project using the Define, Measure, Analyze, Improve and Control (DMAIC) method. Knowledge was evaluated through a 25 item questionnaire administered before (pre) and after (post) rotation. Topics included definitions, surveillance, isolation, preventive methods, outbreak investigation, policies, antibiotic stewardship, healthcare economics, and leadership. Results Sixteen fellows have participated in the rotation (2017-2019); all completed the pre- and post- evaluations (same questionnaire). Fellows answered a mean of 11.1/25 questions correctly pre-course (SD 2.3). Scores improved significantly to a mean of 21.2/25 correct answers at the end of the course (SD 2.6, P< 0.001). All fellows presented quality improvement proposals at the end of the rotation, with a mean score of 85.7% (SD 4.6). The fellows were highly satisfied with the course with mean evaluation score 6.2/7 (88.5%). Conclusion The one month duration infection control and antibiotic stewardship rotation that provides basic training in the field at the beginning of the fellowship led to significant improvement in the fellows’ knowledge, and was very well received. An additional track has been implemented during the second year to prepare interested fellows for careers in infection control and/or antibiotic stewardship. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | | | | | | | | | - Jose Serpa
- Baylor College of Medicine, Houston, Texas
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Carlson TJ, Ryan Russo H, Phe K, Al Mohajer M. 1037. A Pharmacist-Driven 48 Hour Antibiotic Time Out Pilot at a Large Academic Medical Center. Open Forum Infect Dis 2019. [PMCID: PMC6810962 DOI: 10.1093/ofid/ofz360.901] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The Centers for Disease Control and Prevention published The Core Elements of Hospital Antibiotic Stewardship Programs in 2014, which recommended that all clinicians perform an antibiotic time out (ATO) after 48 hours. The best methods to operationalize these recommendations remain unclear. Given our information technology barriers, we developed a targeted, pharmacist-driven, 48 hour ATO pilot. Methods This pre-post intervention pilot study included hospitalized adults admitted to one of the four wards between 5/1/18 and 6/30/18. Patients who received ≥48 hours of broad-spectrum intravenous antibiotics (vancomycin, piperacillin–tazobactam, cefepime, a carbapenem, or a fluoroquinolone) were prospectively identified via TheraDoc (Premier Inc., Charlotte, NC). An infectious diseases (ID) trained pharmacist reviewed patients on a daily basis during June. The primary outcome was days of therapy (DOT), which was assessed with Spearman’s rank-order correlation. All P-values were from 2-sided tests, and results were deemed statistically significant at P < 0.05. Results A total of 151 unique patients were identified during the study period. The most common antibiotic indications were skin and soft-tissue infection (31.1%), urinary tract infection (22.5%), and intraabdominal infection (22.5%). An ID physician was consulted on 59% of patients. The pharmacist reviewed an average of 7 patients (3 unique) each day during the intervention month. A total of 27 recommendations were made with 15 (56%) being accepted. The most common recommendations were to de-escalate therapy (n = 8), stop antibiotics (n = 6), and add a stop date to the antibiotic order (n = 4). DOT in the pre- and post-intervention period did not differ (P = 0.28). Conclusion A month-long, targeted, pharmacist-driven, 48 hour ATO pilot was unable to demonstrate a reduction in DOT. Furthermore, only 56% of pharmacist recommendations were accepted despite targeting low-acuity infections, which may have limited our ability to observe a reduction in DOT. Larger studies are warranted to further evaluate how ATOs influence DOT over time. Disclosures All authors: No reported disclosures.
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Affiliation(s)
| | - Hannah Ryan Russo
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center, Houston, Texas
| | - Kady Phe
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center, Houston, Texas
| | - Mayar Al Mohajer
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center; Baylor College of Medicine, Houston, Texas
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Ryan Russo H, Phe K, Al Mohajer M, Hirase J. 1998. Impact of Rapid Blood Culture Identification with Real-Time Antimicrobial Stewardship (ASP) in Patients with Staphylococcus aureus (S. aureus) and Enterococcus spp. Bacteremia at a Large Academic Medical Center. Open Forum Infect Dis 2019. [PMCID: PMC6809225 DOI: 10.1093/ofid/ofz360.1678] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The initiation of appropriate antimicrobial therapy is dependent on timely identification of the pathogen. FilmArray Blood Culture Identification Panel (BCID) is a rapid, multiplex polymerase chain reaction (PCR) panel that identifies 24 pathogens and 3 antibiotic resistance genes associated with bloodstream infections within 1 hour of growth. The purpose of this study was to compare the clinical impact of rapid BCID testing vs. standard blood culture processing, both coupled with real-time ASP, in patients with S. aureus and Enterococcus spp. bacteremia. Methods This was a single-center, retrospective chart review conducted as a pre-post intervention quasi-experimental study. The pre-intervention group included adult patients with S.aureus and Enterococcus spp. bacteremia identified by standard blood culture processing (PRE) and the post-intervention group included those identified by rapid BCID testing (POST). The primary endpoint was time in hours from positive Gram stain to initiation of optimal antimicrobial therapy [defined as vancomycin (VAN), linezolid (LZD), daptomycin (DAP), or ceftaroline for methicillin-resistant S. aureus (MRSA); nafcillin or cefazolin for methicillin-susceptible S. aureus (MSSA); DAP or LZD for VAN-resistant Enterococcus (VRE); VAN or ampicillin (if susceptible) for VAN-susceptible Enterococcus (VSE)]. Secondary endpoints included time to active therapy (defined as an antimicrobial to which the organism was susceptible), time to identification of pathogen, length of hospital stay (LOS) after positive culture, and 30-day mortality. Results 132 patients were included. Mean time to optimal therapy decreased from 21.4 hours PRE to 10.7 hours POST (P = 0.048). Time to optimal therapy was shorter POST for MSSA [59.2 hours PRE vs. 25.8 hours POST (P < 0.001)] and VRE bacteremia [24.6 hours PRE vs. 5.6 hours POST (P = 0.005)]. Time to identification of pathogen decreased from 75.6 hours PRE to 2.7 hours POST (P < 0.001). Groups did not differ in time to active therapy, LOS, nor 30-day mortality. Conclusion Antimicrobial Stewardship coupled with rapid BCID testing significantly decreased time to pathogen identification as well as time to optimal therapy in patients with S. aureus and Enterococcus spp. bacteremia, most notably for MSSA and VRE. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Hannah Ryan Russo
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center, Houston, Texas
| | - Kady Phe
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center, Houston, Texas
| | - Mayar Al Mohajer
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center; Baylor College of Medicine, Houston, Texas
| | - Jessica Hirase
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center, Houston, Texas
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Clark E, Kulkarni PA, Mohajer MA, Rose S, Serpa J, Singhal G, Giordano T. 2551. Optimizing Rounding Efficiency on the Infectious Diseases Inpatient Service: A Multi-Generational Conversation. Open Forum Infect Dis 2019. [PMCID: PMC6809596 DOI: 10.1093/ofid/ofz360.2229] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background To optimize faculty and trainee wellness without compromising patient care and trainee education, it is important to develop efficient team rounding strategies. This quality improvement project describes rounding practices and suggestions for optimizing rounding efficiency on Infectious Diseases (ID) inpatient consult services at a large academic institution. Methods An anonymous survey on rounding strategies was distributed to the ID Section at Baylor College of Medicine in February 2019 as part of a facilitated discussion on optimizing clinical education for fellows. Results Twenty-seven members of the ID section completed the survey (17 faculty, 10 fellows). Fellows reported rounding for a median of 4 hours per day (range 3–5), while faculty reported 4.5 hours (range 2–5.5). When asked what time fellows should start their workday, the median response was 7:30 am from both fellows (range 6:30–8 am) and faculty (range 7–8 am). When asked what time fellows should end their work day, the median response was 5:30 pm from both fellows (range 5–6 pm) and faculty (range 5–7 pm). Fellows reported signing their last note at 5:30 pm (range 5–9 pm), vs. 9 pm for faculty (range 6–11 pm). Regarding rounding method, most respondents (100% of fellows and 77% of faculty) preferred a combination of traditional rounding at patient bedside and “table” rounds. Regarding teaching method, most faculty (64%) preferred bedside teaching, while most fellows (60%) preferred teaching presentations in the work room (P = 0.011, Fisher’s exact). Both fellows and faculty had many suggestions for optimizing rounding efficiency; the most common was to avoid having fellows see all patients twice daily (“double rounding,” suggested by 80% of fellows and 30% of faculty). Conclusion Overall, the reported behaviors of fellows regarding the structure of their days on inpatient ID services coincided with faculty expectations, although preferences differed between fellows and faculty regarding teaching methods. Avoiding “double rounding” was the most common suggestion to optimize efficiency. Larger studies are needed to better understand rounding behavior and strategies that will optimize the efficiency and effectiveness of inpatient ID consult teams. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Eva Clark
- Baylor College of Medicine, Houston, Texas
| | - Prathit A Kulkarni
- Baylor College of Medicine/Michael E. DeBakey VA Medical Center, Houston, Texas
| | - Mayar Al Mohajer
- CHI St. Luke’s Health - Baylor St. Luke’s Medical Center; Baylor College of Medicine, Houston, Texas
| | | | - Jose Serpa
- Baylor College of Medicine, Houston, Texas
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Majeed A, Sagar F, Latif A, Hassan H, Iftikhar A, Darouiche RO, Mohajer MA. Does antimicrobial coating and impregnation of urinary catheters prevent catheter-associated urinary tract infection? A review of clinical and preclinical studies. Expert Rev Med Devices 2019; 16:809-820. [PMID: 31478395 DOI: 10.1080/17434440.2019.1661774] [Citation(s) in RCA: 15] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Catheter-associated urinary tract infection (CAUTI) is one of the most common nosocomial infections in hospitals, accounting for 36% of all health care-associated infections. Areas covered: We aimed to address the potential impact of antimicrobial coating of catheter materials for the prevention of CAUTI and to analyze the progress made in this field. We conducted literature searches in the PubMed, Embase, and Cochrane Library databases, and found 578 articles. Data from 60 articles in either the preclinical or clinical stage were analyzed in this expert review. Expert opinion: The literature review revealed many promising methods for preventing CAUTI. Recent studies have suggested the combination of silver-based products and antibiotics, owing to their synergistic effect, to help address the problem of antibiotic resistance. Other coating materials that have been tested include nitric oxide, chlorhexidine, antimicrobial peptides, enzymes, and bacteriophages. Because of heterogeneity among studies, it is difficult to reliably comment on the clinical efficacy of different coating materials. Future research should focus on double-blind randomized clinical trials for evaluating the role of these potential coating agents.
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Affiliation(s)
- Aneela Majeed
- Division of Infectious Diseases, Department of Medicine, Stanford University , Stanford , CA , USA
| | - Fnu Sagar
- Department of Medicine, University of Arizona , Tucson , AZ , USA
| | - Azka Latif
- Department of Medicine, Creighton University , Omaha , NE , USA
| | - Hamza Hassan
- Department of Medicine, Rochester General Hospital , Rochester , NY , USA
| | - Ahmad Iftikhar
- Department of Medicine, University of Arizona , Tucson , AZ , USA
| | - Rabih O Darouiche
- Section of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center Baylor College of Medicine , Houston , TX , USA.,Section of Infectious Diseases, Baylor College of Medicine , Houston , TX , USA
| | - Mayar Al Mohajer
- Section of Infectious Diseases, Baylor College of Medicine , Houston , TX , USA
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Hooten R, Luis Marquez J, Goldlist K, Urcis R, Adams M, Matthias KR, Nix DE, Al Mohajer M. Overprescription of antibiotics in patients with community-acquired pneumonia in the intensive care unit. Avicenna J Med 2019; 9:107-110. [PMID: 31404133 PMCID: PMC6647917 DOI: 10.4103/ajm.ajm_189_18] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Purpose: We aimed to assess factors associated with therapy failure in patients with community-acquired pneumonia in the intensive care unit (ICU). Methods: Electronic charts of patients with International Classification of Diseases, Ninth Revision, codes of pneumonia who were admitted to the ICU at a tertiary academic medical center in Southern Arizona were reviewed. Results: Antipseudomonal coverage and anti-methicillin-resistant Staphylococcus aureus (MRSA) coverage were often prescribed (58.4% and 54.1%, respectively). Antipseudomonal coverage was rarely necessary as pseudomonal pneumonia was found in only one case (0.9%). Antipseudomonal and anti-MRSA coverage was not associated with improved outcomes. Conclusion: Overprescription of antibiotics in this population remains a significant problem. More work is needed to further limit unnecessary antibiotic use.
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Affiliation(s)
- Rorak Hooten
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Jose Luis Marquez
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Kady Goldlist
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Rafael Urcis
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Matthew Adams
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Kathryn R Matthias
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - David E Nix
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Chow NA, Toda M, Pennington AF, Anassi E, Atmar RL, Cox-Ganser JM, Da Silva J, Garcia B, Kontoyiannis DP, Ostrosky-Zeichner L, Leining LM, McCarty J, Al Mohajer M, Murthy BP, Park JH, Schulte J, Shuford JA, Skrobarcek KA, Solomon S, Strysko J, Chiller TM, Jackson BR, Chew GL, Beer KD. Hurricane-Associated Mold Exposures Among Patients at Risk for Invasive Mold Infections After Hurricane Harvey - Houston, Texas, 2017. MMWR Morb Mortal Wkly Rep 2019; 68:469-473. [PMID: 31145717 PMCID: PMC6542480 DOI: 10.15585/mmwr.mm6821a1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
In August 2017, Hurricane Harvey caused unprecedented flooding and devastation to the Houston metropolitan area (1). Mold exposure was a serious concern because investigations after Hurricanes Katrina and Rita (2005) had documented extensive mold growth in flood-damaged homes (2,3). Because mold exposure can cause serious illnesses known as invasive mold infections (4,5), and immunosuppressed persons are at high risk for these infections (6,7), several federal agencies recommend that immunosuppressed persons avoid mold-contaminated sites (8,9). To assess the extent of exposure to mold and flood-damaged areas among persons at high risk for invasive mold infections after Hurricane Harvey, CDC and Texas health officials conducted a survey among 103 immunosuppressed residents in Houston. Approximately half of the participants (50) engaged in cleanup of mold and water-damaged areas; these activities included heavy cleanup (23), such as removing furniture or removing drywall, or light cleanup (27), such as wiping down walls or retrieving personal items. Among immunosuppressed persons who performed heavy cleanup, 43% reported wearing a respirator, as did 8% who performed light cleanup. One participant reported wearing all personal protective equipment (PPE) recommended for otherwise healthy persons (i.e., respirator, boots, goggles, and gloves). Immunosuppressed residents who are at high risk for invasive mold infections were exposed to mold and flood-damaged areas after Hurricane Harvey; recommendations from health care providers to avoid exposure to mold and flood-damaged areas could mitigate the risk to immunosuppressed persons.
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Zhou Y, Hemmige V, Dalai SC, Hong DK, Muldrew K, Mohajer MA. Utility of Whole-Genome Next-Generation Sequencing of Plasma in Identifying Opportunistic Infections in HIV/AIDS. Open AIDS J 2019. [DOI: 10.2174/1874613601913010007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background:AIDS-associated Opportunistic Infections (OIs) have significant morbidity and mortality and can be diagnostically challenging, requiring invasive procedures as well as a combination of culture and targeted molecular approaches.Objective:We aimed to demonstrate the clinical utility of Next-generation Sequencing (NGS) in pathogen identification; NGS is a maturing technology enabling the detection of miniscule amounts of cell-free microbial DNA from the bloodstream.Methods:We utilized a novel Next-generation Sequencing (NGS) test on plasma samples to diagnose a series of HIV-associated OIs that were diagnostically confirmed through conventional microbial testing.Results:In all cases, NGS test results were available sooner than conventional testing. This is the first case series demonstrating the utility of whole-genome NGS testing to identify OIs from plasma in HIV/AIDS patients.Conclusion:NGS approaches present a clinically-actionable, comprehensive means of diagnosing OIs and other systemic infections while avoiding the labor, expense, and delays of multiple tests and invasive procedures.
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Abstract
PURPOSE To identify the factors associated with total Hospital-Acquired Condition Reduction Program (HACRP) score and with receiving a Centers for Medicare and Medicaid Services (CMS) penalty (1% reduction in payment to those hospitals in the lowest-performing quartile of HACRP scores) for fiscal years (FYs) 2015-2017 with a particular focus on trends over this period. METHOD The authors evaluated the following variables: (1) type of hospital (teaching vs. nonteaching); (2) disproportionate patient percentage; (3) case mix index (CMI); (4) number of staffed beds; (5) length of stay (LOS); (6) gross patient revenue; and (7) region, using data from CMS and the American Hospital Directory. They conducted multivariate linear and logistic regressions. RESULTS A total of 2,249 hospitals were included. The mean total HACRP scores across hospitals for FY15, FY16, and FY17 were 5.38, 5.35, and 5.18, respectively. In FY15, 21.2% (476/2,249) of hospitals received a penalty compared with 22.6% (508/2,249) in FY16 and 31.3% (704/2,249) in FY17 (P < .001). The logistic regression model showed that teaching hospitals, larger hospitals (> 400 beds), hospitals with high CMI or long LOS, and hospitals in the Northeast and Western United States were more likely to receive a penalty. Teaching hospitals and larger hospitals did not improve their scores over time compared with nonteaching and small hospitals. CONCLUSIONS A reevaluation of the scoring methodology for the HACRP is needed. CMS could stratify hospitals into homogeneous categories and apply penalties to those that have the worst scores in each category.
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Affiliation(s)
- Mayar Al Mohajer
- M. Al Mohajer is associate professor of medicine, Department of Medicine, Baylor College of Medicine, Houston, Texas. K.A. Joiner is professor of medicine and economics, Center for Management Innovations in Health Care, Eller College of Management, University of Arizona, Tucson, Arizona. D.E. Nix is professor of pharmacy, Department of Pharmacy Science and Practices, University of Arizona, Tucson, Arizona
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Majeed A, Mushtaq A, Iftikhar A, Zahid U, Sagar F, Usman M, Fraz M, Mohajer MA. 302. Role of Inflammatory Markers in Diagnosing Diabetic Foot Infection: A Meta-Analysis. Open Forum Infect Dis 2018. [PMCID: PMC6254127 DOI: 10.1093/ofid/ofy210.313] [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] [Indexed: 11/14/2022] Open
Abstract
Background Diabetic foot ulcers (DFUs) cause significant morbidity and put great economic burden on patient and healthcare facilities. Infection is the main driving force behind admissions related to DFU. Culture of soft tissue or bone is invaluable in diagnosing infection but is time consuming. Inflammatory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) are rapid, simple, and inexpensive laboratory tests that can aid in early diagnosis of diabetic foot infection (DFI) and monitor response to treatment. We did a meta-analysis to compare diagnostic performance of inflammatory markers for detecting DFI. Methods We searched PubMed, Embase, and Cochrane databases from their inception to December 2017. This meta-analysis was performed according to PRISMA guidelines. We included studies based on following inclusion criteria: (1) at least one of the biomarkers (ESR, CRP, PCT) was evaluated; (2) both sensitivity and specificity were measured as outcomes; and (3) sufficient data were available to construct 2 × 2 contingency table. We used bivariate random effect regression model to pool the sensitivity and specificity of the targeted biomarkers. Results A comprehensive literature search identified a total of 73 studies. Twelve studies met our inclusion criteria. Number of studies reporting data on each individual biomarker was as follows: 11 for ESR, seven for CRP, and five for PCT. Pooled sensitivity and specificity for ESR were calculated to be 0.84 (95% CI 0.76–0.89) and 0.82 (95% CI 0.73–0.89) with area under receiver operating characteristic curve (AUROC) of 0.90 (95% CI 0.87–0.92). Pooled sensitivity and specificity for CRP were found to be 0.64 (95% CI 0.46–0.80) and 0.87 (95% CI 0.75–0.93) with AUROC of 0.85 (95% CI0.82–0.88). Pooled sensitivity and specificity for PCT were 0.74 (95% CI 0.62–0.83) with AUROC of 0.84 (95% CI 0.81–0.87). Conclusion ESR could be beneficial in ruling out infection in persons who have low suspicion of disease. For those who have high suspicion of disease, PCT could be helpful in ruling in infection. Clinicians should avoid ordering both ESR and CRP because role of CRP is limited. All inflammatory markers need standardization of threshold levels for detecting infection. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Aneela Majeed
- Department of Medicine, Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona
| | | | | | | | - Fnu Sagar
- University of Arizona, Tuscon, Arizona
| | | | | | - Mayar Al Mohajer
- Infection Prevention and Control-Bslmc, Baylor College of Medicine, Houston, Texas
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Barber E, Phe K, Russo HP, Mohajer MA. 589. Assessment of an Antiretroviral Therapy Policy in Patients with Human Immunodeficiency Virus at a Large Academic Medical Center. Open Forum Infect Dis 2018. [PMCID: PMC6253919 DOI: 10.1093/ofid/ofy210.596] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Background Accurate medication reconciliation upon hospital admission is crucial for patients with human immunodeficiency virus (HIV) to ensure continuation of appropriate antiretroviral therapy (ART). An ART policy was implemented at our institution which restricted ART ordering to infectious diseases physicians to increase appropriate ART prescribing following admission. The purpose of this study was to evaluate the effectiveness of the HIV medication restriction policy on the appropriateness of ART re-ordering upon admission. Methods This was a single-center, retrospective chart review conducted from July 2014 to June 2017 as a pre–post intervention study. The pre-intervention group included adult patients with HIV who received one or more doses of ART prior to implementation of the HIV medication restriction policy. The post-intervention group included adult patients with HIV who received one or more doses of ART after implementation of the policy. Exclusion criteria included patients who received ART for hepatitis B infection or prophylaxis, HIV post-exposure prophylaxis, or patients receiving a first dose of ART for occupational exposure. Home ART medication regimen and inpatient ART medication regimen were evaluated. The primary endpoint was to compare the rate of appropriate medication reconciliations completed before and after implementation of the HIV medication restriction policy. The secondary endpoint was to compare the time to restart of ART following admission. Results A total of 115 patients were included in this study. Appropriate medication reconciliation increased from 76% to 100% after implementation of the policy (P = 0.014). However, the mean time to re-initiation of ART increased from 7.9 hours to 14.5 hours after implementation of the policy (P = 0.01). ART regimens were restarted within 24 hours of admission in 96.7% of the pre-HIV policy group vs. 84% in the post-HIV policy group (P = 0.02). Conclusion The mean time to re-initiation of ART increased after implementation of the HIV policy. However, restriction of ART ordering to infectious diseases physicians significantly increased the rate of appropriate medication reconciliation for patients with HIV. In light of these results, a procedure will be established to ensure the timely re-initiation of ART. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Elizabeth Barber
- CHI St. Luke’s Health – Baylor St. Luke’s Medical Center, Houston, Texas
| | - Kady Phe
- CHI St. Luke’s Health – Baylor St. Luke’s Medical Center, Houston, Texas
| | | | - Mayar Al Mohajer
- Department of Medicine, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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Beatty NL, Hager KM, McKeown KR, Mora F, Matthias KR, Nix DE, Mohajer MA. Influenza vaccine availability at urgent care centers in the state of Arizona. Am J Infect Control 2018; 46:946-948. [PMID: 29609855 DOI: 10.1016/j.ajic.2018.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/07/2018] [Accepted: 02/07/2018] [Indexed: 10/17/2022]
Abstract
We surveyed urgent care centers (UCCs) in the state of Arizona to determine whether they offered the influenza vaccine during the 2016-2017 influenza season. Overall vaccine availability was 80.3% at these facilities. During this season, one-third of the UCCs offered influenza vaccination to children 6 months or older; approximately two-thirds offered influenza vaccination to children and young adults 16 years or older. This is the first study of influenza vaccine availability at UCCs.
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40
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Zahid U, Sagar F, Al Mohajer M, Majeed A. Management of Recurrent Clostridium difficile Infection During Intensive Chemotherapy and Stem Cell Transplantation for Leukemia: Case with Literature Review. Cureus 2018; 10:e2413. [PMID: 29872594 PMCID: PMC5984265 DOI: 10.7759/cureus.2413] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Immunocompromised patients undergoing chemotherapy for hematologic malignancy and hematopoietic stem cell transplant (HSCT) recipients are at increased risk of Clostridium difficile (C. difficile) infection (CDI). The recurrence of infection and its associated morbidity and mortality are due to multiple risk factors. Diarrhea is common in HSCT recipients, but the diagnosis of diarrhea caused by CDI is a therapeutic challenge due to frequent Clostridium difficile colonization with diarrhea secondary to non-infectious causes. The high recurrence rate is a significant challenge in the treatment of immunocompromised patients. Close monitoring of the patients, timely diagnosis, preventive measures, treatment with antibiotics, and the removal of offending agents can help in the management and cure of the disease. We review the literature on management and describe a patient with acute lymphoblastic leukemia (ALL) with multiple recurrences of CDI during leukemia therapy and allogeneic stem cell transplantation for leukemia.
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Affiliation(s)
- Umar Zahid
- Internal Medicine, University of Arizona, Tucson, USA
| | - Fnu Sagar
- Internal Medicine, University of Arizona, Tucson, USA
| | | | - Aneela Majeed
- Internal Medicine, University of Arizona, Tucson, USA
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41
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Beatty N, Nix D, August J, Swazo R, Kottey J, Mckeown K, Alshibani M, Petty W, Matthias K, Al Mohajer M. Appropriateness of a Rapid Multiplex Gastrointestinal Panel in the Investigation of Suspected Infectious Diarrhea After Implementation at an Academic Medical Center. Open Forum Infect Dis 2017. [PMCID: PMC5630856 DOI: 10.1093/ofid/ofx163.878] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The BioFire FilmArray™ Gastrointestinal (GI) Panel is a 1 hour multiplex real-time PCR test that can detect the presence of 22 GI pathogens (viral, bacterial, and parasitic) known to cause infectious diarrhea. Our tertiary-care academic medical center implemented the GI Panel for all cases of suspected infectious diarrhea replacing the previous conventional testing once utilized to detect GI pathogens. Since its implementation we have not had any criteria for ordering this test to aid healthcare providers.
Methods
The aim of this IRB approved, retrospective investigation was to determine the appropriateness of ordering the GI panel at our academic institution. Cases were randomly selected, stratified by age group and result (specific pathogens or negative result) from May 2015 through April 2016 in the post-implementation period (n = 400 of 1117 total tests). We developed appropriateness criteria for ordering the GI panel which included: passage of at least 3 unformed stools in 24 hours plus one or more enteric symptom (nausea, vomiting, abdominal pain/cramps, tenesmus, fecal urgency, moderate to severe flatulence), and one of the following: grossly bloody diarrhea (dysenteric), persistent diarrhea (14 – 30 days), worsening or relapsing diarrhea, fever ≥ 101 F°, severe diarrhea > 10 bouts in 24hrs, immunosuppression, pregnancy, food handler, infant < 1 year and their care takers, age ≥ 65 years old, concern for disseminated GI infection, with no previous GI panel testing in the past 30 days.
Results
Overall appropriateness of GI panel testing based off our generated criteria was 36% (n = 144/400). This included all tests ordered in the outpatient clinics, emergency department, inpatient medical/surgical wards, and intensive care units.
Conclusion
Currently there is not a well-established standard criteria for ordering the GI panel for investigating suspected infectious diarrhea. After implementation at our academic tertiary-care medical center the GI panel was used inappropriately in most cases without a criteria for ordering in place to aid clinicians. Educating healthcare providers about appropriate testing indications is being performed. Further studies are needed to assess if our generated criteria will lead to decreased costs and unnecessary testing.
Disclosures
All authors: No reported disclosures.
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Affiliation(s)
- Norman Beatty
- Internal Medicine, University of Arizona College of Medicine at South Campus, Tucson, Arizona
| | - David Nix
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Jessica August
- Internal Medicine, University of Arizona College of Medicine at South Campus, Tucson, Arizona
| | - Roberto Swazo
- Internal Medicine, University of Arizona College of Medicine at South Campus, Tucson, Arizona
| | - Janame Kottey
- Internal Medicine, University of Arizona College of Medicine at South Campus, Tucson, Arizona
| | - Kyle Mckeown
- University of Arizona College of Medicine, Tucson, Arizona
| | - Mohannad Alshibani
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
- College of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Wanda Petty
- Department of Pathology, Banner University Medical Center, Tucson, Arizona
| | - Kathryn Matthias
- Department of Pharmacy Practice and Science, University of Arizona College of Pharmacy, Tucson, Arizona
| | - Mayar Al Mohajer
- Department of Medicine, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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42
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Affiliation(s)
| | - Jose Marquez
- University of Arizona College of Medicine, Tucson, Arizona
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43
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Beatty N, Brown C, Zangeneh T, Al Mohajer M. A rare case of Mycobacterium abscessus subspecies abscessus prosthetic valve endocarditis and the clinical importance of inducible erm(41) gene testing. BMJ Case Rep 2017; 2017:bcr-2017-219618. [PMID: 28611136 DOI: 10.1136/bcr-2017-219618] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 56-year-old man with a history of injection drug use and two prior episodes of native valve infective endocarditis presented with dyspnoea on exertion. Our preliminary work-up revealed bacteraemia with reported growth of 'Mycobacterium abscessus group' on multiple blood cultures. The patient was later found to have eustachian valve and prosthetic pulmonic valve endocarditis. Initially, he responded to standard antimycobacterial therapy for rapidly growing mycobacteria (RGM) with supporting laboratory susceptibilities. However, he later developed refractory disease and persistent bacteraemia in the setting of these alleged susceptible antibiotics. Further molecular testing revealed a functional and inducible erm(41) gene which confers macrolide resistance. A subspecies analysis of the M abscessus group revealed the subspecies to be abscessus We present a challenging case of M abscessus subsp. abscessus bacteraemia and prosthetic valve endocarditis with further discussion on treatment and management of this infection along with the taxonomic complexity of this ubiquitous RGM.
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Affiliation(s)
- Norman Beatty
- Department of Medicine, Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Craig Brown
- Department of Medicine, Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Tirdad Zangeneh
- Department of Medicine, Division of Infectious Diseases, University of Arizona College of Medicine, Tucson, Arizona, USA
| | - Mayar Al Mohajer
- Department of Medicine, Baylor College of Medicine,Division of Infectious Diseases, Houston, Texas, USA
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44
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Eljaaly K, Alshehri S, Aljabri A, Abraham I, Al Mohajer M, Kalil AC, Nix DE. Clinical failure with and without empiric atypical bacteria coverage in hospitalized adults with community-acquired pneumonia: a systematic review and meta-analysis. BMC Infect Dis 2017; 17:385. [PMID: 28576117 PMCID: PMC5457549 DOI: 10.1186/s12879-017-2495-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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: 02/27/2017] [Accepted: 05/25/2017] [Indexed: 11/18/2022] Open
Abstract
Background Both typical and atypical bacteria can cause community-acquired pneumonia (CAP); however, the need for empiric atypical coverage remains controversial. Our objective was to evaluate the impact of antibiotic regimens with atypical coverage (a fluoroquinolone or combination of a macrolide/doxycycline with a β-lactam) to a regimen without atypical antibiotic coverage (β-lactam monotherapy) on rates of clinical failure (primary endpoint), mortality, bacteriologic failure, and adverse events, (secondary endpoints). Methods We searched the PubMed, EMBASE and Cochrane Library databases for relevant RCTs of hospitalized CAP adults. We estimated risk ratios (RRs) with 95% confidence intervals (CIs) using a fixed-effect model, but used a random-effects model if significant heterogeneity (I2) was observed. Results Five RCTs with a total of 2011 patients were retained. A statistically significant lower clinical failure rate was observed with empiric atypical coverage (RR, 0.851 [95% CI, 0.732–0.99; P = 0.037]; I2 = 0%). The secondary outcomes did not differ between the two study groups: mortality (RR = 0.549 [95% CI, 0.259–1.165, P = 0.118], I2 = 61.434%) bacteriologic failure (RR = 0.816 [95% CI, 0.523–1.272, P = 0.369], I2 = 0%), diarrhea (RR = 0.746 [95% CI, 0.311–1.790, P = 0.512], I2 = 65.048%), and adverse events requiring antibiotic discontinuation (RR = 0.83 [95% CI, 0.542–1.270, P = 0.39], I2 = 0%). Conclusions Empiric atypical coverage was associated with a significant reduction in clinical failure in hospitalized adults with CAP. Reduction in mortality, bacterial failure, diarrhea, and discontinuation due to adverse effects were not significantly different between groups, but all estimates favored atypical coverage. Our findings provide support for the current guidelines recommendations to include empiric atypical coverage. Electronic supplementary material The online version of this article (doi:10.1186/s12879-017-2495-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Khalid Eljaaly
- Department of Clinical Pharmacy, King Abdulaziz University, P.O. Box 80200, Jeddah, Postal code 21589, Saudi Arabia. .,College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA.
| | - Samah Alshehri
- Department of Clinical Pharmacy, King Abdulaziz University, P.O. Box 80200, Jeddah, Postal code 21589, Saudi Arabia.,College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA
| | - Ahmed Aljabri
- Department of Clinical Pharmacy, King Abdulaziz University, P.O. Box 80200, Jeddah, Postal code 21589, Saudi Arabia.,College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA
| | - Ivo Abraham
- College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA
| | - Mayar Al Mohajer
- Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Andre C Kalil
- Department of Internal Medicine, Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, NE, USA
| | - David E Nix
- College of Pharmacy, University of Arizona, Drachman Hall - B306, 1295 N Martin Ave, P.O.Box 210202, Tucson, AZ, USA.,Division of Infectious Diseases, Department of Medicine, University of Arizona, Tucson, AZ, USA
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45
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Tager D, Hatch A, Segar J, Roller B, Al Mohajer M, Zangeneh TT. Coccidioidal meningitis complicated by central nervous system vasculitis in a patient with leukemia. Med Mycol Case Rep 2017; 16:8-11. [PMID: 28386527 PMCID: PMC5374848 DOI: 10.1016/j.mmcr.2017.03.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 03/16/2017] [Accepted: 03/22/2017] [Indexed: 11/17/2022] Open
Abstract
Central Nervous System (CNS) vasculitis is the most common life-threatening complication of coccidioidal meningitis. It is manifested by cerebral ischemia, hemorrhage, and infarction. We report a case of CNS vasculitis in a patient receiving chemotherapy and review of the literature on coccidioidal meningitis. The patient was treated with combination antifungal therapy and a short course of high dose corticosteroids with a modest improvement in her neurological examination after initiation of steroids.
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Affiliation(s)
- Dany Tager
- University of Arizona, College of Medicine, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Anne Hatch
- Department of Neurology, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Jennifer Segar
- Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Brentin Roller
- Division of Infectious Diseases, Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Mayar Al Mohajer
- Division of Infectious Diseases, Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
| | - Tirdad T. Zangeneh
- Division of Infectious Diseases, Department of Medicine, Banner University Medical Center, University of Arizona, 1501 N Campbell Ave, Tucson, AZ 85724, USA
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46
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Nair A, Elliott SP, Al Mohajer M. Knowledge, attitude, and practice of blood culture contamination: A multicenter study. Am J Infect Control 2017; 45:547-548. [PMID: 28214162 DOI: 10.1016/j.ajic.2017.01.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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: 11/27/2016] [Revised: 01/07/2017] [Accepted: 01/09/2017] [Indexed: 11/16/2022]
Abstract
We developed a questionnaire to assess the knowledge and practice of nursing staff, patient care assistants, phlebotomists, and laboratory technicians regarding blood culture collection and contamination at 2 tertiary care academic centers. Our study showed there were several gaps in knowledge and practice regarding obtaining blood cultures.
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Affiliation(s)
- Archana Nair
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ
| | - Sean P Elliott
- Department of Pediatrics, College of Medicine, University of Arizona, Tucson, AZ
| | - Mayar Al Mohajer
- Department of Medicine, College of Medicine, University of Arizona, Tucson, AZ.
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Ong E, Farran S, Salloum M, Gardner S, Giovinco N, Armstrong DG, Matthias KR, Nix DE, Al Mohajer M. Does Everything That’s Counted Count? Value of Inflammatory Markers for Following Therapy and Predicting Outcome in Diabetic Foot Infection. INT J LOW EXTR WOUND 2017; 16:104-107. [DOI: 10.1177/1534734617700539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
To assess the severity of inflammation associated with diabetic foot infection (DFI), values of inflammatory markers such as white blood count (WBC), C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and neutrophil to lymphocyte ratio (NLR) are often measured and tracked over time. It remains unclear if these markers can aid the clinician in the diagnosis and management of DFI, and ensure more rational use of antibiotics. Hospitalized adult patients (n = 379) with DFI were retrospectively assessed for abnormal inflammatory markers, correlation between values of inflammatory markers, and clinical diagnosis on initial admission and on last follow-up. At admission, WBC, ESR and NLR were each elevated in patients with osteomyelitis and only ESR was significantly elevated in patients with soft tissue infection only. Only WBC was significantly elevated in patients with osteomyelitis compared with uninfected diabetic feet on last follow-up. Considering the predictive performance of these inflammatory markers, they demonstrated excellent positive predictive value at admission, and excellent negative predictive value at the last follow-up visit. Moreover, the number of elevated markers was further associated with probability of infection both at admission and last follow-up.
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Affiliation(s)
- Eric Ong
- University of Arizona, Tucson, AZ, USA
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48
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Majeed A, Abdullah HMA, Ullah W, Al Mohajer M. First reported case of disseminated Nocardia kroppenstedtii sp nov. infection presenting with brain abscess and endocarditis in an immunocompromised patient with mantle cell lymphoma: challenges in diagnosis and treatment. BMJ Case Rep 2017; 2017:bcr-2016-217337. [PMID: 28062425 DOI: 10.1136/bcr-2016-217337] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
A 72-year-old man with a history of blastoid variant stage IV relapsed refractory mantle cell lymphoma presented with new central nervous system (CNS) symptoms. Brain imaging was positive for rim-enhancing lesions along with a mitral valve mass on the echocardiogram. It was a challenge to establish the exact aetiology of these lesions in this patient. He was empirically treated with chemotherapy on the presumption that the brain lesions were secondary to progressive malignancy. However, brain biopsy was negative for malignancy and blood cultures were found positive for Nocardia kroppenstedtii sp nov. He subsequently improved with antibiotic therapy. Disseminated Nocardia can present with multiorgan involvement. Clinical and microbiological diagnosis can be challenging. Antimicrobial treatment-related side effects require close monitoring, and dosage changes or therapy adjustments may be necessary.
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Affiliation(s)
| | | | - Waqas Ullah
- Department of Internal Medicine, Khyber Teaching Hospital, Peshawar, Khyber Pakhtunkhwa, Pakistan
| | - Mayar Al Mohajer
- Department of Internal Medicine, University of Arizona, Tucson, Arizona, USA
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49
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Beatty N, Hager K, Mckeown K, Mora F, Matthias K, Nix D, Al Mohajer M. 2016–2017 Seasonal Influenza Vaccine Availability at Urgent Care Centers in the state of Arizona, USA. Open Forum Infect Dis 2017. [DOI: 10.1093/ofid/ofx163.1354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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50
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Al Mohajer M, Matthias KR, Nix DE. Improving the knowledge of students and physicians regarding appropriate use of antibiotics for respiratory infections through an online educational module. Am J Infect Control 2017; 45:e15-e17. [PMID: 27839751 DOI: 10.1016/j.ajic.2016.09.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 09/02/2016] [Accepted: 09/06/2016] [Indexed: 10/20/2022]
Abstract
We developed an interactive online module to improve the knowledge of students and physicians regarding respiratory infections. Our study showed that the completion of this module was associated with substantial improvement in knowledge, with modest retention after 2 months.
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