Brandon Dionne

In outpatient parenteral antimicrobial therapy, weekly lab monitoring is often standard practice, even for antimicrobials with low complication rates. We reviewed 420 patients treated with cefazolin: lab abnormalities associated with readmission or treatment changes occurred in 2% of patients. Reduced-frequency monitoring may be reasonable for patients treated with cefazolin outpatient.

Background: Current vancomycin monitoring guidelines recommend monitoring 24-hour area under the concentration-time curve (AUC) to minimum inhibitory concentration ratios for patients with serious methicillin-resistant Staphylococcus aureus infections. However, there are sparse data on the safety, feasibility, and efficacy of vancomycin AUC monitoring for outpatients. Traditional AUC pharmacokinetic calculations require 2 concentrations, while bayesian software allows for single-concentration AUC estimations. Methods: We conducted a single-center, quasi-experimental, interrupted time series study of patients enrolled in the outpatient parenteral antimicrobial therapy program at our institution for vancomycin management. Our institution implemented a pharmacist-driven vancomycin AUC monitoring program from September 2019 to February 2020, and again from September 2022 to March 2023. Patients enrolled underwent vancomycin monitoring using an AUC goal of 400–600 mg⋅h/L, estimated through bayesian modeling. Patients enrolled in the outpatient parenteral antimicrobial therapy program from July 2021 through August 2022 for trough-based monitoring were used for comparison. The primary outcome was nephrotoxicity incidence, defined as a serum creatinine increase by ≥0.5 mg/dL or ≥50% during outpatient vancomycin therapy. Results: We enrolled 63 patients in the AUC group and 60 patients in the trough-based group. Nephrotoxicity was significantly lower in the AUC cohort (6.3% vs 23.3%; P = .01). The number of unusable vancomycin concentrations was also significantly lower in the AUC cohort (0% vs 6%; P < .01). There was no difference in composite 90-day all-cause mortality or readmission (33.3% vs 38.3%; P = .56). Conclusions: Following implementation of a pharmacist-driven AUC monitoring program, patients were less likely to develop nephrotoxicity during outpatient vancomycin therapy.

An estimated 25% of U.S. nursing home residents may have an antibiotic resistant infection. Antibiotic resistance is primarily driven by antibiotic use, thus, increasing our understanding of trends in antibiotic use within nursing homes is needed to address this public health threat. Our study examined changes in antibiotic prescriptions among nursing home residents using claims data from January 2018 through December 2020. Linked files from Medicare Part D and the Minimum Dataset 3.0 covering years 2018-2020 were used to describe antibiotic use in U.S. nursing homes via nationwide trend analysis. Over two million adults, aged 65 years and older, who were covered by Medicare Part D for the entire duration of their stay were included. Changes in trends by antibiotic class and U.S. region were also assessed. From 2018 through 2019, antibiotic prescribing rates remained relatively unchanged in U.S. nursing homes. However, there were differences by antibiotic class and U.S. region. There was a large increase in the use of both oral and IV antibiotics in 2020, most likely due to confounding factors introduced by the COVID-19 pandemic. All Authors: No reported disclosures

Introduction: It has been estimated that nearly 50% of antibiotics are inappropriately prescribed in the outpatient setting. Despite much discussion surrounding the importance of reducing these occurrences, the literature is limited in describing antibiotic prescribing patterns for urinary tract infections (UTIs) in the primary care setting.Objectives: The primary objective of this study was to evaluate if antibiotics for UTIs in primary care settings are prescribed concordantly with evidence‐based guidelines.Methods: This retrospective cohort study reviewed female patients 18 years and older treated in a primary care setting with a diagnosis of uncomplicated UTI. Treatment was analyzed for appropriateness of empiric antibiotic choice, duration of therapy, and dose. This information was then compared with treatment recommendations for UTIs per the 2010 Infectious Diseases Society of America (IDSA) guidelines. Antibiotic prescribing patterns were also analyzed in relation to the 2016 United States Food and Drug Administration (FDA) safety warning for fluoroquinolones.Results: A total of 388 UTI encounters over the 42‐month study period were included for analysis. Sulfamethoxazole/trimethoprim was the most frequently prescribed antibiotic (50.0%) followed by nitrofurantoin (26.3%) and fluoroquinolones (16.8%). A total of 71.6% of antibiotic agents selected for treatment of UTIs were not first line agents per the 2010 IDSA guidelines, which increased to 92.3% when considering dosing, duration, and renal adjustments. Culture and susceptibility results led to changes in empiric therapy, yet only 38.1% of the changes were considered guideline concordant. Linear regression comparing pre‐ and post‐FDA warnings indicated a 15% reduction in the proportion of fluoroquinolone prescriptions (P < .001).Conclusion: A large disparity exists between antibiotic prescribing patterns and IDSA guideline recommendations. By identifying divergences from standards of practice, pharmacists can justify the need to integrate stewardship programs into primary care settings in order to optimize patient care.

Chronic granulomatous disease (CGD) is a primary immunodeficiency syndrome that results in increased risk for bacterial and fungal infections, as well as inflammatory/autoimmune complications. While CGD historically has been associated with early death in childhood, the life expectancy and morbidity of patients with CGD have greatly improved. Many patients with CGD now survive well into adulthood, and data on adult cohorts of patients with CGD have been published. However, reports of pregnancy management, complications, and outcomes for patients with CGD are sparse. In addition, management of invasive fungal infections, including use of newer triazole antifungals, during pregnancy has not been well described. We report a case of fungal lung infection in a pregnant woman with CGD, diagnosed during her second trimester, which was treated with multiple antifungal agents, including more than 12 weeks of isavuconazole therapy, resulting in resolution of infection and delivery of a healthy newborn at term.

Background: Antimicrobial stewardship programs (ASPs) aim to provide optimal antimicrobial therapy to patients quickly to improve the likelihood of overcoming infection while reducing the risk of adverse effects. Rapid diagnostic tests (RDTs) for infectious diseases have become an integral tool for ASPs to achieve these aims. Content: This review explored the demonstrated clinical value of longer-standing technologies and implications of newer RDTs from an antimicrobial stewardship perspective. Based on available literature, the focus was on the use of RDTs in bloodstream infections (BSIs), particularly those that perform organism identification and genotypic resistance detection, phenotypic susceptibility testing, and direct specimen testing. Clinical implications of rapid testing among respiratory, central nervous system, and gastrointestinal infections are also reviewed. Summary: Coupling RDTs with ASPs facilitates the appropriate and timely use of test results, translating into improved patient outcomes through optimization of antimicrobial use. These benefits are best demonstrated in the use of RDT in BSIs. Rapid phenotypic susceptibility testing offers the potential for early pharmacokinetic/pharmacodynamic optimization, and direct specimen testing on blood may allow ASPs to initiate appropriate therapy and/or tailor empiric therapy even sooner than other RDTs. RDTs for respiratory, central nervous system, and gastrointestinal illnesses have also shown significant promise, although more outcome studies are needed to evaluate their full impact.

Background: Splenic injury can occur through multiple mechanisms and may result in various degrees of residual immunocompetence. Functionally or anatomically asplenic patients are at higher risk for infection, particularly with encapsulated bacteria. Vaccination is recommended to prevent infection with these organisms; however, the recommendations are routinely updated, and vaccine selection and timing are complex. Methods: Review of the pertinent English-language literature, including the recommendations of the U.S. Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices. Results: Overwhelming post-splenectomy infection is associated with high morbidity and mortality rates. Patients requiring splenectomy for trauma-related injury appear to be at lower risk for infection than those undergoing splenectomy for a hematologic or oncologic indication. Initial vaccination is dependent on immunization history but generally should consist of the 13-valent pneumococcal conjugate, quadrivalent meningococcal conjugate, meningococcal serogroup B, and Haemophilus influenzae serotype b (Hib) vaccines. Antimicrobial prophylaxis for certain asplenic patients, such as children under the age of five y, may be indicated. Conclusion: Immunization remains a key measure to prevent overwhelming post-splenectomy infection. Consideration of new recommendations and indications, possible interactions, and timing remains important to including optimal response to the vaccines.