We describe the multiple steps necessary to create a successful PSP focused on physicians and midlevel providers. There is an unmet need to provide support to this group of healthcare providers after medical errors and adverse events.

Objective To assess the impact of sepsis classification and multidrug resistance status on outcome in patients receiving appropriate initial antibiotic therapy. Design A retrospective cohort study. Setting Barnes-Jewish Hospital, a 1250-bed teaching hospital. Patients Individuals with Enterobacteriaceae sepsis, severe sepsis, and septic shock that received appropriate initial antimicrobial therapy between June 2009 and December 2013. Interventions Clinical outcomes were compared according to multidrug resistance status, sepsis classification, demographics, severity of illness, comorbidities, and antimicrobial treatment. Measurements and Main Results We identified 510 patients with Enterobacteriaceae bacteremia and sepsis, severe sepsis, or septic shock. Sixty-seven patients (13.1%) were non-survivors. Mortality increased significantly with increasing severity of sepsis (3.5%, 9.9%, and 28.6%, for sepsis, severe sepsis, and septic shock, respectively, p<0.05). Time to antimicrobial therapy was not significantly associated with outcome. APACHE II was more predictive of mortality than age-adjusted Charlson comorbidity index. Multidrug resistance status did not result in excess mortality. Length of intensive care unit and hospital stay increased with more severe sepsis. In multivariate logistic regression analysis, African-American race, sepsis severity, APACHE II score, solid organ cancer, cirrhosis, and transfer from an outside hospital were all predictors of mortality. Conclusions Our results support sepsis severity, but not multidrug resistance status as being an important predictor of death when all patients receive appropriate initial antibiotic therapy. Future sepsis trials should attempt to provide appropriate antimicrobial therapy and take sepsis severity into careful account when determining outcomes.

Objective To identify current outpatient parenteral antibiotic therapy practice patterns and complications. Methods We administered an 11 question survey to adult infectious disease physicians participating in the Emerging Infections Network (EIN), a CDC-sponsored sentinel event surveillance network in North America. The survey was distributed electronically or via facsimile in November and December 2012. Respondent demographic characteristics were obtained from EIN enrollment data. Results Overall, 555 (44.6%) of EIN members responded to the survey with 450 (81%) indicating they treated ≥ 1 patient with OPAT during an average month. ID consultation was reported to be required for a patient to be discharged on OPAT by 99 (22%) respondents. Inpatient (282/449; 63%) and outpatient (232/449; 52%) ID physicians were frequently identified as being responsible for monitoring lab results. Only 26% (118/448) had dedicated OPAT teams at their clinical site. Few ID physicians have systems to track errors, adverse events or “near-misses” associated with OPAT (97/449; 22%). OPAT complications were perceived to be rare. Among respondents, 80% reported line occlusion/clotting as the most common complication (occurring in ≥6% of patients), followed by nephrotoxicity and rash (each reported by 61%). Weekly lab monitoring of patients on vancomycin was reported by 77% (343/445) of respondents; whereas 19% (84/445) of respondents reported twice weekly lab monitoring for these patients. Conclusions Although utilization of OPAT is common, there is significant variation in practice patterns. More uniform OPAT practices may enhance patient safety.

Paragonimiasis (human infections with the lung fluke Paragonimus westermani) is an important public health problem in parts of Southeast Asia and China. Paragonamiasis has rarely been reported from North America as a zoonosis caused by Paragonimus kellicotti. Paragonimus species have complex life cycles that require 2 intermediate hosts, namely, snails and crustaceans (ie, crabs or crayfish). Humans acquire P. kellicotti when they consume infected raw crayfish. Humans with paragonimiasis usually present with fever and cough, which, together with the presentation of hemoptysis, can be misdiagnosed as tuberculosis. Only 7 autochthonous cases of paragonimiasis have been previously reported from North America. Our study describes 3 patients with proven or probable paragonimiasis with unusual clinical features who were seen at a single medical center during an 18-month period. These patients acquired their infections after consuming raw crayfish from rivers in Missouri. It is likely that other patients with paragonimiasis have been misdiagnosed and improperly treated. Physicians should consider the possibility that patients who present with cough, fever, hemoptysis, and eosinophilia may have paragonimiasis.

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