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Background. Infectious diseases (ID) consultation and antimicrobial stewardship intervention have been shown to improve the management of Staphylococcus aureus bacteremia (SAB). As the workload of antimicrobial stewardship programs (ASPs) continues to increase, ASPs must find a way to maximize the efficiency of the program while optimizing patient outcomes. The objective of this study was to evaluate the impact of incorporating health informatics into the management of SAB via a pharmacist-driven initiative. Methods. Retrospective, single-center quasi-experimental study of hospitalized patients with SAB. During the intervention period, pharmacists were alerted to patients with SAB via a patient scoring tool integrated into the electronic medical record. Pharmacists utilized the scoring tool and the institution's evidence-based practice guideline to make standardized recommendations to promote adherence to SAB quality-of-care measures and encourage ID consultation. The primary outcome was overall compliance along with adherence to individual quality-of-care components. Secondary clinical outcomes were also analyzed. Results. In sum, 84 patients were identified for study inclusion, 45 in the pre-intervention and 39 in the intervention group. As a whole, all 4 quality-of-care components for the management of SAB were significantly more frequently adhered to in the intervention group (68.9% vs 92.3%; P = .008). The incidence of ID consult improved significantly by almost 20% in the intervention group (75.6% vs 94.9%, P = .015). No statistically significant differences in duration of bacteremia, length-of-stay, infection-related length-of-stay, or readmission were observed between the groups. The incidence of all-cause mortality was 6-fold higher in the pre-intervention group compared to the intervention group (15.6% vs 2.6%, P = .063). Conclusion. An automated, pharmacist-driven intervention for the management of patients with SAB demonstrated a significant improvement in patients receiving an ID consult, targeted antimicrobial therapy, and adherence to all SAB quality-of-care measures. As antimicrobial stewardship becomes a mandatory aspect of healthcare in all hospitals in the United States, ASPs will be forced to find ways to provide more efficient, impactful, disease state-based patient care. Our study provides the framework for and data to support this intervention in one of the most clinically important infectious diseases.

The American Thoracic Society and Infectious Diseases Society of America provide guidelines for management of hospital-acquired, ventilator-associated, and health-care-associated pneumonias, consisting of empirical antibiotic regimens for patients at risk for multidrug-resistant pathogens. We aimed to improve compliance with these guidelines and assess outcomes. We implemented a performance-improvement initiative in four academic medical centres in the USA with protocol-based education and prospective observation of outcomes. Patients were assessed for severity of illness and followed up until death, hospital discharge, or day 28. We included patients in intensive-care units who were at risk for multidrug-resistant pneumonia and were treated empirically. 303 patients at risk for multidrug-resistant pneumonia were treated empirically, and prescribed treatment was guideline compliant in 129 patients and non-compliant in 174 patients. 44 (34%) patients died before 28 days in the compliance group and 35 (20%) died in the non-compliance group. Five patients in the compliance group and seven in the non-compliance group were lost to follow-up after day 14. Kaplan-Meier estimated survival to 28 days was 65% in the compliance group and 79% in the non-compliance group (p=0·0042). This difference persisted after adjustment for severity of illness. Median length of stay and duration of mechanical ventilation did not differ between groups. Compliance failures included non-use of dual treatment for Gram-negative pathogens in 154 patients and absence of meticillin-resistant Staphylococcus aureus coverage in 24 patients. For patients in whom pathogens were subsequently identified, empirical treatment was active in 79 (81%) of 97 of patients receiving compliant therapy compared with 109 (85%) of 128 of patients receiving non-compliant therapy. Because adherence with empirical treatment was associated with increased mortality, we recommend a randomised trial be done before further implementation of these guidelines. Pfizer, US Medical.

We conducted a prospective, multicenter observational study of adults (n = 1447) and children (n = 144) with candidemia at tertiary care centers in the United States in parallel with a candidemia treatment trial that included nonneutropenic adults. Candida albicans was the most common bloodstream isolate recovered from adults and children (45% vs. 49%) and was associated with high mortality (47% among adults vs. 29% among children). Three-month survival was better among children than among adults (76% vs. 54%; P < .001). Most children received amphotericin B as initial therapy, whereas most adults received fluconazole. In adults, Candida parapsilosis fungemia was associated with lower mortality than was non-parapsilosis candidemia (24% vs. 46%; P < .001). Mortality was similar among subjects with Candida glabrata or non-glabrata candidemia; mortality was also similar among subjects with C. glabrata candidemia who received fluconazole rather than other antifungal therapy. Subjects in the observational cohort had higher Acute Physiology and Chronic Health Evaluation II scores than did participants in the clinical trial (18.6 vs. 16.1), which suggests that the former subjects are more often excluded from therapeutic trials.

Background The concerns of the highly contagious and morbid nature of Coronavirus Disease-2019 (COVID-2019) have prompted healthcare workers to implement strict droplet and contact isolation precautions. Unfortunately, some patients who may be or presumptively or confirmed as infected with COVID-2019 may also require emergent surgical procedures. As such, given the high-risk for exposure of many healthcare workers involved the complex requirements for appropriate isolation must be adhered to. Case presentation We present our experience with a 77-year-old who required emergency cardiac surgery for a presumed acute aortic syndrome in the setting of a presumed, and eventually confirmed, COVID-2019 infection. We outline the necessary steps to maintain strict isolation precautions to limit potential exposure to the surgical Team. Conclusions We hereby provide our algorithm for emergent surgical procedures in critically-ill patients with presumptive or confirmed infection with COVID-2019. The insights from this case report can potentially be templated to other facilities in order to uphold high standards of infection prevention and patient safety in surgery during the current COVID-19 pandemic.

Background. Minocycline is an \"old-drug\" with Food and Drug Administration approval for the treatment of infection due to Acinetobacter species. The purpose of this study is to describe an Antimicrobial Stewardship Program's evaluation of minocycline for the treatment of patients with multidrug resistant A. baumannii (MDR-AB) infections. Methods. This study evaluated hospitalized adult patients (September 2010 through March 2013) who received minocycline intravenously (IV) for a MDR-AB infection. Clinical and microbiological outcomes were analyzed. Secondary outcomes included infection-related mortality, length of hospital stay (LOS), infection-related LOS, intensive care unit (ICU) LOS, mechanical ventilation days, and 30-day readmission. Results. A total of 55 patients received minocycline. Median age was 56 (23–85) years, 65% were male with an APACHE II score of 21 (4–41). Clinical success was achieved in 40/55 (73%) patients treated with minocycline monotherapy (n = 3) or in combination with a second active agent (n = 52). Overall 43 (78%) patients demonstrated documented or presumed microbiologic eradication. Infection-related mortality was 25%. Hospital LOS was 31 (5–132) and infection-related LOS was 16 (2–43) days. Forty-seven (85%) patients were admitted to the ICU for a LOS of 18 (2–78) days. Thirty-nine (71%) patients required mechanical ventilation for 6 (2–29) days. One patient had a 30-day readmission. Conclusions. The response rate to minocycline monotherapy or in combination for the treatment of MDR-AB infections is encouraging as therapeutic options are limited. Prospective studies in patients with MDR-AB infections will help establish the role of minocycline alone or in combination with other antimicrobials.

Background. Invasive candidiasis is the third most common bloodstream infection in the intensive care unit (ICU) and is associated with morbidity and mortality. Prophylaxis and preemptive therapy are attractive strategies for this setting. Methods. We conducted a multicenter, randomized, double-blind, placebo-controlled trial of caspofungin as antifungal prophylaxis in 222 adults who were in the ICU for at least 3 days, were ventilated, received antibiotics, had a central line, and had 1 additional risk factor (parenteral nutrition, dialysis, surgery, pancreatitis, systemic steroids, or other immunosuppressants). Subjects' (1,3)-β-D-glucan levels were monitored twice weekly. The primary endpoint was the incidence of proven or probable invasive candidiasis by EORTC/MSG criteria in patients who did not have disease at baseline. Patients who had invasive candidiasis were allowed to break the blind and receive preemptive therapy with caspofungin. The preemptive approach analysis included patients all patients who received study drug, including those positive at baseline. Results. The incidence of proven/probable invasive candidiasis in the placebo and caspofungin arms was 16.7% (14/84) and 9.8% (10/102), respectively, for prophylaxis (P = .14), and 30.4% (31/102) and 18.8% (22/117), respectively, for the preemptive approach (P = .04); however, this analysis included patients with baseline disease. There were no significant differences in the secondary endpoints of mortality, antifungal use, or length of stay. There were no safety differences. Conclusions. Caspofungin was safe and tended to reduce the incidence of invasive candidiasis when used for prophylaxis, but the difference was not statistically significant. A preemptive therapy approach deserves further study. Clinical Trials Registration. NCT00520234.

Objective:To investigate hospital room and patient-level risk factors associated with increased risk of healthcare-facility–onset Clostridioides difficile infection (HO-CDI).Design:The study used a retrospective cohort design that included patient data from the institution’s electronic health record, existing surveillance data on HO-CDI, and a walk-through survey of hospital rooms to identify potential room-level risk factors. The primary outcome was HO-CDI diagnosis.Setting:A large academic medical center.Patients and participants:All adult patients admitted between January 1, 2015, and December 31, 2016 were eligible for inclusion. Prisoners were excluded. Patients who only stayed in rooms that were not surveyed were excluded.Results:The hospital room survey collected room-level data on 806 rooms. Included in the study were 17,034 patients without HO-CDI and 251 with HO-CDI nested within 535 unique rooms. In this exploratory study, room-level risk factors associated with the outcome in the multivariate model included wear on furniture and flooring and antibiotic use by the prior room occupant. Hand hygiene devices and fixed in-room computers were associated with reduced odds of a HO-CDI. Differences between hospital buildings were also detected. The only individual patient factors that were associated with increased odds of HO-CDI were antibiotic use and comorbidity score.Conclusion:Combining a hospital-room walk-through data collection survey, EHR data, and CDI surveillance data, we were able to develop a model to investigate room and patient-level risks for HO-CDI.

The explosion of medical applications (apps) in the Apple and Google Play app stores has made it increasingly difficult to find relevant and reliable infectious diseases (ID) apps. Apple created a section called \"Apps for Healthcare Professionals\"; however, several ID apps are missing. Google Play's ID category has several non-ID apps. Many apps involve diagnosis and patient management, creating a need for regulations and oversight by the US Food and Drug Administration. There are no standards to guide accuracy or reliability of medical apps' content. We searched Apple and Google Play app stores to identify new ID apps. Over 1200 apps were identified. We applied several exclusion criteria to identify adult/pediatric apps with data from trustworthy sources that were not reviewed within the last year. Twelve new ID apps were identified with a comprehensive list of 24 ID apps to assist healthcare professionals at the point of care.

We studied 83 cardiac-surgery patients with nasal S. aureus carriage who received 4 intranasal administrations of XF-73 nasal gel or placebo <24 hours before surgery. One hour before surgery, patients exhibited a S. aureus nasal carriage reduction of 2.5 log10 with XF-73 compared to 0.4 log10 CFU/mL for those who received placebo (95% CI, −2.7 to −1.5; P < .0001).

Abstract Background Private practice dentists represent 72% of United States dentists. We conducted a prospective cohort study of private practice dentists comparing antibiotic use before and after dental antibiotic stewardship education by infectious diseases (ID) antibiotic stewardship experts. Methods Study phases were as follows: phase 1 (preeducation), 3 months of retrospective antibiotic data and a presurvey assessed baseline antibiotic knowledge; phase 2 (education), dentists attended 3 evening Zoom sessions; phase 3, (posteducation/interventions), 3 months of prospective audits with weekly feedback; phase 4, postsurvey and recommendations to reach more dentists. Results Fifteen dentists participated. Ten had practiced >20 years. Presurvey, 14 were unfamiliar with dental stewardship. The number of antibiotic prescriptions pre/post decreased from 2124 to 1816 (P < .00001), whereas procedures increased from 8526 to 9063. Overall, appropriate use (prophylaxis and treatment) increased from 19% pre to 87.9% post (P < .0001). Appropriate prophylaxis was 46.6% pre and 76.7% post (P < .0001). Joint implant prophylaxis decreased from 164 pre to 78 post (P < .0001). Appropriate treatment antibiotics pre/post improved 5-fold from 15% to 90.2% (P = .0001). Antibiotic duration pre/post decreased from 7.7 days (standard deviation [SD], 2.2 days) to 5.1 days (SD, 1.6 days) (P < .0001). Clindamycin use decreased 90% from 183 pre to 18 post (P < .0001). Postsurvey responses recommended making antibiotic stewardship a required annual continuing education. Study participants invited ID antibiotic stewardship experts to teach an additional 2125 dentists via dental study clubs. Conclusions After learning dental antibiotic stewardship from ID antibiotic stewardship experts, dentists rapidly optimized antibiotic prescribing. Private practice dental study clubs are expanding dental antibiotic stewardship training to additional dentists, hygienists, and patients across the United States. Dentists significantly improved appropriate antibiotic use from 19% to 87.9% after antibiotic stewardship education with audit and weekly feedback interventions by infectious diseases experts. Their national network of dental study clubs continues to engage additional dentists in dental antibiotic stewardship. Graphical Abstract Graphical Abstract