Ashley M. Wilde

Objective: To describe the screening practice of nasal methicillin-resistant Staphylococcus aureus (MRSA) polymerase chain reaction (PCR) among nine health organizations in Kentucky. Methods: The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) invited its Advisory Board members to share their nasal MRSA PCR protocols and guidelines. The documents were examined to highlight institutional similarities and differences. Results: Nine health systems, including both community hospitals and academic medical centers, responded to the KASIC request. Most systems with nasal MRSA PCR testing capacity had established protocols or guidelines to support its appropriate use. All institutions recommended nasal MRSA PCR for pneumonia indications while three organizations also used it for non-pneumonia indications. None of these institutions permitted pharmacists to discontinue anti-MRSA antibiotics per protocol. Conclusions: This study provides the first statewide overview of nasal MRSA PCR screening practices, offering stewardship programs a framework to customize their own protocols and guidelines.

Antimicrobial stewardship (AMS) is an important tool in the fight against antimicrobial resistance. However, many areas of the world suffer from lack of access to healthcare professionals with AMS training. The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) was created to address such inequities in Kentucky, USA. Regional AMS centres of excellence such as KASIC are an effective strategy to improve AMS efforts. Global accreditation of regional AMS centres of excellence may potentiate AMS internationally.

Background: Staphylococcus aureus bacteraemia confers significant morbidity and mortality. A multi-disciplinary team was created to optimize bacteraemia management. Methods: The intervention included integration of rapid diagnostic blood culture processing and a multi-disciplinary approach to real-time management of results. This was a retrospective, pre–post study to compare outcomes in the standard of care (SOC, n = 50) and intervention (n = 100) groups of patients with community-onset S. aureus bacteraemia. Patients were excluded for death before Gram stain result, leaving against medical advice, polymicrobial bacteraemia or withdrawal of life sustaining treatments during hospitalization. The primary outcome was 30-day all-cause mortality. Secondary outcomes were in-hospital, 6 month and 1 year mortality as well as S. aureus-related readmission and time to effective antibiotic therapy. Results: 54% of the SOC group and 46% of the intervention group had methicillin-resistant S. aureus infections. The primary outcome, 30-day mortality, was 3% in the intervention group compared to 20% in the SOC group (P = 0.004). There was no difference in in-hospital mortality (P = 0.08) but lower mortality in the intervention group at 30 days (P = 0.003), 6 months (P = 0.005) and 1 year (P < 0.001). S. aureus-related readmission was significantly lower at 31 days–6 months after discharge in the intervention group. Median time to effective antibiotic therapy was 13 h versus 6.3 h in the SOC and intervention groups, respectively. Conclusions: The integration of real-time rapid diagnostic blood culture technology tied to immediate clinical actions was associated with improved time to effective therapy and mortality in patients with community-onset S. aureus bacteraemia.

Detection of viral RNA in nasopharyngeal (NP) samples by reverse transcription polymerase chain reaction (RT-PCR) is the standard diagnostic test for influenza or respiratory syncytial virus (RSV) in hospitalized patients with community-acquired pneumonia (CAP). This study compared the sensitivity of RT-PCR using NP swab, saliva, and sputum samples for the diagnosis of CAP due to influenza or RSV. A total of 60 patients were evaluated, of which 40 (67%) had influenza CAP, 19 (32%) had RSV CAP, and one patient (1%) had both RSV and influenza CAP. RT-PCR on NP swab, saliva, and sputum samples was performed using the Luminex ARIES platform. In patients with influenza CAP, the sensitivity was 34% for NP swabs, 68% for saliva, and 71% for sputum. In patients with RSV CAP, the sensitivity was 60% for NP swabs, 75% for saliva, and 85% for sputum. RT-PCR of nasopharyngeal swab samples was associated with a significant number of false negative results. A negative NP swab RT-PCR test should not be used to rule out CAP due to influenza or RSV. Saliva and sputum samples should be considered when performing a microbiological work-up in patients with suspected influenza or RSV CAP.

Background: Most epidemiologic studies and clinical testing use single nasal/nasopharyngeal swab (NPS) for respiratory syncytial virus (RSV) detection. Studies document that RSV detection improves if another specimen is added to NPS, but the impact of using multiple specimen types has not been assessed. We quantified RSV detection increase using multiple-specimen testing versus NPS alone. Methods: Hospitalized adults aged ≥40 years with acute respiratory illness were prospectively enrolled in 7 US/Canadian hospitals. NPS, saliva, sputa, and acute/convalescent sera were collected and tested. Results: Among 3669 participants, 100% had NPS, 97.7% saliva, 33.0% sputum, and 33.4% paired serology. RSV detection was 112% higher (95% CI, 86%–141%) using all specimen types as compared with NPS alone. Serology test sensitivity was the highest (73.0%; 95% CI, 65.1%–80.8%), followed by sputum (70.1%; 95% CI, 62.1%–78.0%), saliva (61.4%; 95% CI, 55.4%–67.5%), and NPS (47.2%; 95% CI, 41.1%–53.4%). Among those with congestive heart failure exacerbations, additional specimens increased detection by 267% (95% CI, 85%–625%), and saliva detected more infections than NPS. Among 1013 participants with paired NPSs from different time points, specimens collected on average 1 day later detected 30% fewer RSV infections. Conclusions: RSV detection increased >100% using 4 specimen types, suggesting a 2-fold correction factor is appropriate for incidence and prevalence studies relying on NPS alone. Saliva was more sensitive than NPS, warranting further study, particularly in cardiac cases.

Omadacycline is a novel antimicrobial belonging to the tetracycline class. It has the ability to evade both efflux and ribosomal methylation types of resistance and therefore has an expanded spectrum compared to other tetracycline agents. Omadacycline is active against a number of multidrug-resistant bacteria, including macrolide and doxycycline-resistant Streptococcus pneumoniae, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus, and several enteric gram-negative bacilli. It also has activity against many nontuberculous mycobacterium (NTM) species. It is available both orally and intravenously, which allows for feasible switch therapy. This review will assess the antimicrobial activity, pharmacology, safety, and clinical efficacy of omadacycline and present the opinions of the authors on where to position omadacycline for clinical practice.

Introduction: Rapid diagnostic technology can improve patient outcomes, particularly when combined with Antimicrobial Stewardship Program (ASP) intervention. Bacteremic patients due to drug‐resistant organisms are most likely to benefit from rapid diagnostic technologies as they are more likely to be prescribed inadequate empiric therapy. The purpose of this study was to analyze the impact of a pharmacy‐driven Rapid Bacteremia Response Program (RBRP) on the process and clinical outcomes of patients with bacteremia due to an extended‐spectrum beta‐lactamase (ESBL)‐producing organism.Methods: A retrospective, quasi‐experimental study was conducted at a large healthcare system. The RBRP was implemented in 2017 to expedite antimicrobial therapy for bacteremia based on Gram stain and Verigene® system (Luminex Corp, Austin, TX, USA) results. Adults hospitalized with ESBL bacteremia were evaluated pre‐intervention and post‐intervention (utilizing the RBRP). The primary outcome was time to active therapy. Secondary outcomes included in‐hospital and 30‐day mortality, length of hospital and intensive care unit (ICU) stay, and factors associated with mortality.Results: A total of 200 patients were included: 100 patients in the pre‐intervention and 100 patients in the post‐intervention group. The post‐intervention group resulted in 6.4 h faster time to active therapy from blood culture collection (median 22.8 h pre‐intervention vs. 16.4 h post‐intervention, p = 0.001). No statistical difference was identified for the length of hospital or ICU stay and in‐hospital or 30‐day mortality between groups. Multivariable analysis identified age, male sex, quick Pitt bacteremia score, and hospital‐acquired infection to be significantly associated with 30‐day mortality.Conclusion: The pharmacy‐driven RBRP resulted in decreased time to active therapy for patients with ESBL bacteremia.

Objective: To compare rates of Clostridioides difficile infection (CDI) recurrence following initial occurrence treated with tapered enteral vancomycin compared to standard vancomycin.Design: Retrospective cohort study.Setting: Community health system.Patients: Adults ≥18 years of age hospitalized with positive C. difficile polymerase chain reaction or toxin enzyme immunoassay who were prescribed either standard 10–14 days of enteral vancomycin four times daily or a 12-week tapered vancomycin regimen.Methods: Retrospective propensity score pair matched cohort study. Groups were matched based on age < or ≥ 65 years and receipt of non-C. difficile antibiotics during hospitalization or within 6 months post-discharge. Recurrence rates were analyzed via logistic regression conditioned on matched pairs and reported as conditional odds ratios. The primary outcome was recurrence rates compared between standard vancomycin versus tapered vancomycin for treatment of initial CDI.Results: The CDI recurrence rate at 6 months was 5.3% (4/75) in the taper cohort versus 28% (21/75) in the standard vancomycin cohort. The median time to CDI recurrence was 115 days versus 20 days in the taper and standard vancomycin cohorts, respectively. When adjusted for matching, patients in the taper arm were less likely to experience CDI recurrence at 6 months when compared to standard vancomycin (cOR = 0.19, 95% CI 0.07–0.56, p < 0.002).Conclusions: Larger prospective trials are needed to elucidate the clinical utility of tapered oral vancomycin as a treatment option to achieve sustained clinical cure in first occurrences of CDI.

Streptococcus pneumoniae remains a primary pathogen in hospitalized patients with community-acquired pneumonia (CAP). The objective of this study was to define the epidemiology of pneumococcal pneumonia in Louisville, Kentucky, and to estimate the burden of pneumococcal pneumonia in the United States (US). This study was nested in a prospective population-based cohort study of all adult residents in Louisville, Kentucky, who were hospitalized with CAP from 1 June 2014 to 31 May 2016. In hospitalized patients with CAP, urinary antigen detection of 24 S. pneumoniae serotypes (UAD-24) was performed. The annual population-based pneumococcal pneumonia incidence was calculated. The distribution of S. pneumoniae serotypes was characterized. Ecological associations between pneumococcal pneumonia and income level, race, and age were defined. Mortality was evaluated during hospitalization and at 30 days, 6 months, and 1 year after hospitalization. Among the 5402 CAP patients with a UAD-24 test performed, 708 (13%) patients had pneumococcal pneumonia. The annual cumulative incidence was 93 pneumococcal pneumonia hospitalizations per 100,000 adults (95% CI = 91–95), corresponding to an estimated 226,696 annual pneumococcal pneumonia hospitalizations in the US. The most frequent serotypes were 19A (12%), 3 (11%), and 22F (11%). Clusters of cases were found in areas with low incomes and a higher proportion of Black or African American population. Pneumococcal pneumonia mortality was 3.7% during hospitalization, 8.2% at 30 days, 17.6% at 6 months, and 25.4% at 1 year after hospitalization. The burden of pneumococcal pneumonia in the US remains significant, with an estimate of more than 225,000 adults hospitalized annually, and approximately 1 out of 4 hospitalized adult patients dies within 1 year after hospitalization.

Context: Intravenous (IV) to oral (PO) transition of antimicrobial therapy is a common antimicrobial stewardship activity. Inpatient institutions seeking to create new IV to PO switch services or enhance existing services may benefit from a review of practices utilized at other institutions. Objective: The objective of this review is to summarize IV to PO switch practices utilized by healthcare institutions with established antimicrobial stewardship programs across Kentucky. Methods: The Kentucky Antimicrobial Stewardship Innovation Consortium (KASIC) invited pharmacists on the Advisory Board to share current IV to PO switch practices utilized at their institutions. The submitted documents were evaluated in a systematic approach and summarized. Results: Nine of ten institutions represented by the Advisory Board submitted an IV to PO switch practice document for analysis. All institutions utilized pharmacist-driven protocols to allow automatic conversion from IV to PO for select antimicrobials based on specific patient criteria. All protocols included the following antimicrobials eligible for conversion: azithromycin, doxycycline, fluconazole, levofloxacin, linezolid, and metronidazole. Majority of protocols also had inclusion and exclusion criteria based on patient specific factors such as ability to use the enteral route, clinical stability, and infection type. There was variation in the level of restriction placed on conversion eligibility criteria among protocols. Conclusion: IV to PO switch practices for antimicrobials vary across the state of Kentucky. Institutions should tailor protocols based on specific needs, clinical leadership support, and feasibility of implementation.