No abstract

Infections caused by extended-spectrum beta-lactamase (ESBL)-producing bacteria are associated with worse outcomes and have limited treatment options. Carbapenems remain the drug of choice for these infections due to evidence of a mortality benefit and the mixed clinical efficacy associated with piperacillin/tazobactam (PTZ). Though definitive treatment for ESBL infections is well defined, evidence for appropriate empiric therapy remains inconclusive, and the role of rapid molecular assays that identify ESBL has not been evaluated. This multicenter retrospective study at nine Baylor Scott & White Health sites included patients who had positive blood cultures with ESBL-producing bacteria identified by rapid molecular assay and were empirically prescribed PTZ or carbapenems. A total of 117 patients were included in the study; 66 received empiric PTZ and 51 received carbapenems. Results showed no difference in hospital mortality (3% vs 7.8%, P ¼ 0.4), hospital length of stay (6.1% vs 5.9%, P ¼ 0.88), intensive care unit length of stay (4.7% vs 3.3%, P ¼ 0.39), or recurrent ESBL bacteremia (7.6% vs 7.8%, P ¼ 0.99) between the PTZ and carbapenem empiric treatment groups, respectively. In the era of rapid molecular assays, these results suggest that empiric PTZ use and avoidance of empiric carbapenem therapy in the first 24 hours of infection can be considered until a microbiological diagnosis is confirmed.

Background: Rapid molecular diagnostic tests can aid in deescalating antimicrobial therapy prior to final culture and susceptibility reports. Objective: The purpose of this study was to determine whether a new workflow that incorporated pharmacist review of these results reduced time to change in antimicrobial therapy. Methods: This retrospective study analyzed pre- and post-implementation of pharmacist review of positive blood cultures analyzed by rapid diagnostics with clinical recommendations paged to providers. Patients 18 years of age or older initiated on empiric antibiotics were included. The primary outcome was the time to change to targeted antimicrobials. Other outcomes evaluated were rates of Clostridioides difficile (C difficile) infection, inpatient mortality, and intensive care unit and hospital lengths of stay. Results: A total of 199 patients were included, with 98 and 101 patients in the pre- and post-implementation groups, respectively. The median time to change to targeted antimicrobials was significantly reduced with pharmacist intervention from 18.35 to 8.43 hours ( P = 0.042). The groups had similar rates of C difficile infection (1% vs 0%, P = 0.492) and mortality (7.1% vs 5%, P = 0.564). The post-group also had significant reductions in antibiotic days of therapy (10.5 vs 9 days, P = 0.014) and intensive care unit length of stay (3.04 vs 1.44 days, P = 0.046). Median hospital length of stay was similar between the pre- and post-groups (8.5 vs 8 days, P = 0.106), respectively. Conclusion: Incorporating pharmacist review of rapid molecular results of blood cultures decreased time to change to targeted antimicrobials and reduced inpatient antibiotic days of therapy.

Background Surgical site infections (SSIs) after left ventricular assist device (LVAD) implantation are associated with high mortality, while surgical prophylaxis is variable. Methods This retrospective study included adult patients who underwent LVAD implantation at a single center. We compared outcomes in patients who received narrow antimicrobial prophylaxis (cefazolin, vancomycin, or both) to those who received broad antimicrobial prophylaxis (any antimicrobial combination targeting gram‐positive and gram‐negative organisms not included in the narrow group) at 30‐day and 1‐year postimplantation. Cox‐proportional hazards models and log‐rank tests were used for survival analysis. Results Among the 39 and 65 patients comprising narrow and broad groups respectively, there was no difference in rate of SSI at 30 days (6.2% vs. 12.8%, p = .290) and 1 year (16.9% vs. 25.6%, p = .435). Comparing narrow to broad prophylaxis, the risk of mortality (hazard ratio [HR] = 0.44, 95% confidence interval [CI] = 0.15–1.35, logrank p = .14), and composite of mortality and infection was reduced (HR = 0.92, 95% CI = 0.45–1.88, logrank p = .83), but did not reach statistical significance. Most culture positive infections were due to gram‐positive bacteria (70%) and the most common organisms were the Staphylococcus spp (47%). There were no significant differences in the rate of SSI at 1‐year (p = 1.00) and mortality (p = .33) by device type. Conclusions The rates of infection and all‐cause mortality were not different between patients who received narrow or broad prophylaxis. This highlights an opportunity for institutions to narrow their surgical infection prophylaxis protocols to primarily cover gram‐positive organisms.

Numerous risk factors have been linked to invasive candidiasis; however, they are nonspecific and often trigger empiric antifungal therapy in a large number of patients. Identification of more precise predictors could promote judicious use of empiric echinocandins. In this retrospective review, 127 patients with blood cultures positive for Candida spp. were compared to a randomly selected cohort of 134 patients on empiric micafungin for 3 days and with blood cultures negative for Candida spp. Factors associated with candidemia included total parenteral nutrition (TPN; 26.0% vs 15.7%, P D 0.040), multifocal Candida colonization (23.6% vs 3.0%, P < 0.001), and positive 1,3-b-D-glucan assay (95.0% vs 35.0%, P < 0.001). Patients without candidemia on empiric micafungin were more likely to receive antibiotic therapy in the previous 10 days (55.9% vs 79.9%, P < 0.001) and to be taking immunosuppressive medications (11.0% vs 30.6%, P < 0.001). Receipt of TPN (odds ratio [OR] D 2.07, 95% confidence interval [CI], 1.02-4.21), severe sepsis (OR D 2.20, 95% CI, 1.00-4.83), and multifocal Candida colonization (OR D 13.87, 95% CI, 4.43-43.37) were independently associated with candidemia in the multivariable logistic regression model. Therefore, the absence of these risk factors, especially in conjunction with a negative 1,3-b-D-glucan assay, may be used to recommend de-escalation of empiric micafungin therapy.