Meghan N. Jeffres

Background: Daptomycin and linezolid may have more favorable safety and efficacy profiles compared to vancomycin and require less therapeutic monitoring. To capitalize on these advantages, the University of Colorado Hospital relaxed prescribing restrictions and updated local guidance for the treatment of Gram-positive infections, resulting in increased daptomycin and linezolid utilization. The objective of this study was to assess the impact of liberalized daptomycin and linezolid use on minimum inhibitory concentrations (MICs) in Gram-positive organisms. Methods: This retrospective, single-center study included all Staphylococcus and Enterococcus isolates across an 8-year period, including a 3-year follow-up period after implementing practice changes. Organisms were categorized as hospital-acquired (HA) if the culture was collected 48 hours after admission. Interrupted time series analyses were performed to measure changes in geometric mean (GM) of MICs before and after implementation. Results: Minimum inhibitory concentrations from 19 160 isolates were evaluated, of which 7224 were HA. Linezolid use increased to 43.7 days of therapy per 1000 patient days (DOT/1000PD), and daptomycin use increased to 15.7 DOT/1000PD post-implementation. Linezolid GM MICs trended downward pre-implementation, and the trajectory was unaffected by implementation except in coagulase-negative Staphylococcus (CoNS). Daptomycin GM MICs declined pre-implementation among Enterococcus, but not Staphylococcus. Implementation was associated with a significant slope change in vancomycin-resistant Enterococcus (VRE) and HA CoNS. Resistance rates and MIC distributions were not impacted by implementation. Conclusions: The liberalization of daptomycin and linezolid did not result in clinically relevant increases in resistance. Further studies are needed to confirm the durability of these results, specifically among CoNS and VRE.

Background: Pharmacy students should be prepared to evaluate, manage, and de‐label penicillin allergies. It is unknown if, and to what extent, education about allergy management is included within the curriculum of United States Colleges and Schools of Pharmacy (USCSP). This study sought to evaluate if and how penicillin allergy education is delivered and assess faculty perceptions of student readiness.Methods: A cross‐sectional, multicenter, observational survey was developed by infectious diseases (ID) pharmacy faculty and sent to ID faculty or department chairs at 138 USCSP. The 39‐item questionnaire was divided into demographics, incorporation of targeted or aligned penicillin allergy education in the program, penicillin allergy topics delivered, and respondents' perceptions of penicillin allergy education.Results: The survey response rate was 53% (73/138). The USCSP demographics included established for >20 years (65.8%), curriculum length of 4 years (83.6%), semester format (74.0%), and class size of 51–100 students (42.5%). Respondents described the incorporation of targeted or aligned penicillin allergy delivery (47.9%). Targeted delivery occurred in either the required (57.5%) or elective curriculum (31.4%). Topics included definitions/epidemiology (92.8%), cross‐reactivity (92.8%), pathophysiology (88.1%), patient assessment (73.8%), skin testing (71.4%), and desensitization (71.4%). Delivery methods were lecture‐based (92.8%) and case‐based (66.7%). The median perception (scale of 1–10) of student preparedness for evaluating and managing penicillin allergies after completion of the required and elective curriculum was 5.0 (interquartile range [IQR] 3.7–7.0) and 5.0 (3.0–7.3), respectively. Most (52.1%) perceived that penicillin allergy education deserves more time. Faculty from 45% of responding USCSP perceived students to be prepared to evaluate and manage penicillin allergies. Prepared students were more likely to have received case‐based education (54.5% vs. 25.0%, p < 0.01).Conclusion: Penicillin allergy education in USCSP varies considerably. Most ID pharmacist faculty perceived that many students were unprepared to evaluate and manage penicillin allergies, and that more time should be allocated to penicillin allergy education.

Background: Stigmatization of sexually transmitted infections (STIs) threatens provider-patient relationships and contributes to the underutilization of STI services. Media can shape public attitudes toward health care topics by perpetuating or reducing stigma. Given the high prevalence of STIs and the widespread consumption of media, it is essential for health care providers to be cognizant of factors influencing societal perceptions of STI symptoms, transmission, diagnosis, and treatment. Methods: This study is a scoping review of popular films depicting STIs. Full-length English-language narrative films featuring characters with confirmed or suspected STIs were included. Descriptive statistics were used to determine the proportion of characters accurately portrayed with STI symptoms, transmission, diagnosis, and treatment. Results: The final analysis comprised 128 characters from 77 films, with human immunodeficiency virusbeing the most frequently featured STI (42 films, 54.5%). The overall accuracy across all 4 clinical variables of symptoms, transmission, diagnosis, and treatment was 87.4%. Transmission was the most depicted clinical variable, represented in 74 characters (57.8%). All 4 clinical variables were simultaneously depicted in only 4 (3.1%) characters, with 2 characters portraying all 4 clinical variables accurately. Death occurred in 39 characters (30.5%), with human immunodeficiency virus accounting for the majority (82.1%). Conclusions: Most films accurately portrayed STI clinical variables, including symptoms, transmission, diagnosis, and treatment. Rates of individual variable depiction were inconsistent, whereas death secondary to STIs was common. Understanding the portrayal of STIs in popular films can provide valuable insights for clinicians, enabling them to effectively address patient misconceptions and knowledge gaps.

Urinary tract infections (UTIs) are one of the most common infections and are frequently caused by Gram-negative organisms. The rise of resistant isolates has prompted evaluation of alternative therapies, including amoxicillin-clavulanate which has potent activity against Ambler class A enzymes. This study sought to evaluate clinical outcomes of patients with ceftriaxone non-susceptible UTIs receiving amoxicillin-clavulanate or standard of care (SOC). This was a single-center, retrospective, cohort study of adult patients with urinary tract infections caused by a ceftriaxone non-susceptible pathogen who received amoxicillin-clavulanate or SOC. The primary outcome was clinical failure at 90 days. Secondary outcomes included time to failure, isolation of a resistant organism, and hospital length of stay. Fifty-nine patients met study inclusion: 26 received amoxicillin/clavulanate and 33 received SOC. Amoxicillin-clavulanate recipients did not have higher failure rates compared to SOC recipients. For patients requiring hospital admission, hospital length of stay was numerically shorter with amoxicillin-clavulanate. The frequency of amoxicillin-clavulanate and carbapenem-resistant organisms did not differ significantly between groups. Amoxicillin-clavulanate may be a useful alternative therapy for the treatment of ceftriaxone non-susceptible Enterobacterales UTIs.

Cefazolin is a first-line agent for prevention of surgical site infections (SSIs) after total joint arthroplasty. Patients labeled allergic to beta-lactam antibiotics frequently receive clindamycin or vancomycin perioperatively due to the perceived risk of a hypersensitivity reaction after exposure to cefazolin. This single-system retrospective review included patients labeled allergic to penicillin or cephalosporin antibiotics who underwent a primary total hip and/or knee arthroplasty between January 2020 and July 2021. A detailed chart review was performed to compare the frequency of SSI within 90 days of surgery and interoperative hypersensitivity reactions (HSRs) between patients receiving cefazolin and patients receiving clindamycin and/or vancomycin. A total of 1128 hip and/or knee arthroplasties from 1047 patients were included in the analysis (cefazolin n = 809, clindamycin/vancomycin n = 319). More patients in the clindamycin and/or vancomycin group had a history of cephalosporin allergy and allergic reactions with immediate symptoms. There were fewer SSIs in the cefazolin group compared with the clindamycin and/or vancomycin group (0.9% vs 3.8%; P < .001) including fewer prosthetic joint infections (0.1% vs 1.9%). The frequency of interoperative HSRs was not different between groups (cefazolin = 0.2% vs clindamycin/vancomycin = 1.3%; P = .06). The use of cefazolin as a perioperative antibiotic for infection prophylaxis in total joint arthroplasty in patients labeled beta-lactam allergic is associated with decreased postoperative SSI without an increase in interoperative HSR. This graphical abstract is also available at Tidbit: https://tidbitapp.io/tidbits/cefazolin-vs-second-line-antibiotics-for-surgical-site-infection-prevention-after-total-joint-arthroplasty-among-patients-with-a-beta-lactam-allergy

Background: Fluoroquinolones are the second-most prescribed antimicrobial and are frequently associated with causing hypersensitivity reactions. Existing evidence regarding cross-reactivity of fluoroquinolones is limited, offering clinicians little guidance in understanding the implications of selecting an in-class alternative among patients with histories of allergic reactions to fluoroquinolones. The aim of this study was to compare the frequency of immediate hypersensitivity reactions to ciprofloxacin, levofloxacin, and/or moxifloxacin among patients with a history of immediate hypersensitivity to a different fluoroquinolone.Methods: This retrospective chart review included adult patients with a history of an immediate hypersensitivity reaction to ciprofloxacin, levofloxacin, and/or moxifloxacin and a documented prescription for a different fluoroquinolone. The primary outcome was documentation of a hypersensitivity reaction upon second fluoroquinolone exposure.Results: A total of 321 cases met inclusion criteria. Of these cases, 2.5% experienced an immediate hypersensitivity reaction after second fluoroquinolone exposure to ciprofloxacin, levofloxacin, and/or moxifloxacin. Within the ciprofloxacin, levofloxacin, and moxifloxacin index allergy cohorts, the frequency of cross-reactivity was 2.5%, 2.0%, and 5.3%, respectively.Conclusions: Our data suggest that patients with a history of immediate hypersensitivity reaction to ciprofloxacin, levofloxacin, and/or moxifloxacin are at low risk of experiencing a cross-reaction when exposed to a different fluoroquinolone. Avoidance of all fluoroquinolones in this patient population may not be warranted.

In Reply Mraovic et al disagree with the recommendation to administer cefazolin for prophylaxis of surgical site infections to patients with a history of penici

More than 17 million surgical procedures are performed each year in the US.¹ The Centers for Disease Control and Prevention health care–associated infection prevalence survey estimated that there were 110 800 surgical site infections associated with inpatient operations.² Cefazolin, a first-generation cephalosporin, is the guideline-recommended antibiotic for most surgical procedures.^3,4 Cefazolin is the first-line treatment because it is the most widely studied, has the appropriate spectrum of activity against organisms commonly encountered in surgical site infections, is well tolerated, and has a low acquisition cost. However, the 10% of patients reporting a penicillin allergy are less likely to receive cefazolin and more likely to receive clindamycin or vancomycin, resulting in increased odds of developing a surgical site infection.^5,6