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In clinical scenario surveys, inpatient providers were more likely to report continuing inappropriate (odds ratio, 2.02 [95% confidence interval, 1.35–3.03]; P

We evaluated serial fecal microbiota transplant (FMT) by retention enema in patients with severe or severe/complicated Clostridoides difficile infection (CDI) unresponsive to at least 48 hours of standard antibiotic therapy. Of the 15 patients included, despite initial improvement in most patients, only 5 patients sustained cure at 30 days, and serious adverse events occurred in 4 patients.

Our objective was to describe the duration of antibiotic therapy for the management of common outpatient conditions. The median duration of antibiotic courses for most common conditions, except for acute cystitis, was 10 days, in many cases exceeding guideline-recommended durations.

Background Recent literature has highlighted methicillin-resistant Staphylococcus aureus (MRSA) nasal screening as a possible antimicrobial stewardship program tool for avoiding unnecessary empiric MRSA therapy for pneumonia, yet current guidelines recommend MRSA therapy based on risk factors. The objective of this meta-analysis was to evaluate the diagnostic value of MRSA nasal screening in MRSA pneumonia. Methods PubMed and EMBASE were searched from inception to November 2016 for English studies evaluating MRSA nasal screening and development of MRSA pneumonia. Data analysis was performed using a bivariate random-effects model to estimate pooled sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Results Twenty-two studies, comprising 5163 patients, met our inclusion criteria. The pooled sensitivity and specificity of MRSA nares screen for all MRSA pneumonia types were 70.9% and 90.3%, respectively. With a 10% prevalence of potential MRSA pneumonia, the calculated PPV was 44.8%, and the NPV was 96.5%. The pooled sensitivity and specificity for MRSA community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP) were 85% and 92.1%, respectively. For CAP and HCAP both the PPV and NPV increased, to 56.8% and 98.1%, respectively. In comparison, for MRSA ventilated-associated pneumonia, the sensitivity, specificity, PPV, and NPV were 40.3%, 93.7%, 35.7%, and 94.8%, respectively. Conclusion Nares screening for MRSA had a high specificity and NPV for ruling out MRSA pneumonia, particularly in cases of CAP/HCAP. Based on the NPV, MRSA nares screening is a valuable tool for AMS to streamline empiric antibiotic therapy, especially among patients with pneumonia who are not colonized with MRSA.

Author(s): Spivak, Emily S; Burk, Muriel; Zhang, Rongping; Jones, Makoto M; Neuhauser, Melinda M; Goetz, Matthew Bidwell; Cunningham, Francesca E; Management of Urinary Tract Infections Medication Use Evaluation Group; Management of Urinary Tract Infections Medication Use Evaluation Group | Abstract: BackgroundBacteriuria contributes to antibiotic overuse through treatment of asymptomatic bacteriuria (ASB) and long durations of therapy for symptomatic urinary tract infections (UTIs), yet large-scale evaluations of bacteriuria management among inpatients are lacking.MethodsInpatients with bacteriuria were classified as asymptomatic or symptomatic based on established criteria applied to data collected by manual chart review. We examined frequency of treatment of ASB, factors associated with treatment of ASB, durations of therapy, and frequency of complications including Clostridium difficile infection, readmission, and all-cause mortality within 28 days of discharge.ResultsAmong 2225 episodes of bacteriuria, 64% were classified as ASB. After excluding patients with non-UTI indications for antibiotics, 72% of patients with ASB received antibiotics. When evaluating only patients not meeting SIRS criteria, 68% of patients with ASB received antibiotics. The mean (±SD) days of antibiotic therapy for ASB, cystitis, CA-UTI and pyelonephritis were 10.0 (4.5), 11.4 (4.7), 12.0 (6.1), and 13.6 (5.3), respectively. In sum, 14% of patients with ASB were treated for greater than 14 days, and fluoroquinolones were the most commonly used empiric antibiotic for ASB [245/691 (35%)]. Complications were rare but more common among patients with ASB treated with antibiotics.ConclusionsThe majority of bacteriuria among inpatient veterans is due to ASB with high rates of treatment of ASB and prolonged durations of therapy for ASB and symptomatic UTIs.

An essential participant in antimicrobial stewardship who has been unrecognized and underutilized is the "staff nurse." Although the role of staff nurses has not formally been recognized in guidelines for implementing and operating antimicrobial stewardship programs (ASPs) or defined in the medical literature, they have always performed numerous functions that are integral to successful antimicrobial stewardship. Nurses are antibiotic first responders, central communicators, coordinators of care, as well as 24-hour monitors of patient status, safety, and response to antibiotic therapy. An operational analysis of inpatient admissions evaluates these nursing stewardship activities and analyzes the potential benefits of nurses' formal education about, and inclusion into, ASPs.

Bacteriophages were discovered almost a century ago. With the advent of antibiotics, the use of bacteriophages for treatment of infections fell out of favor in Western medicine. In light of the rise of antibiotic resistance, phages and their products (lysins) are rediscovered as antibacterial bioagents. This overview summarizes principles of phage biology and their translation for therapeutic and preventive applications. Examples are presented to highlight their therapeutic promise for prophylaxis and treatment of bacterial infections including multidrug-resistant organisms in humans and animals, and their use as decontaminants of food supplies and environments. Besides research on the in vivo behavior of phages and lysins, dialogues between researchers and regulatory agencies are necessary to publish guidelines for bacteriophage manufacturing and formulation for human use. Only well-designed, double-blind randomized controlled trials will determine if phages and lysins are safe and effective adjuncts or alternatives to antibiotic therapy for infections with multidrug-resistant organisms.

Acute cystitis is one of the most commonly encountered bacterial infections and is responsible for substantial morbidity and high medical costs in the United States and across the globe. Though generally considered to be self-limiting and easily treated with antibiotics, urinary tract infections (UTIs) are often incompletely resolved by antibiotic therapy and frequently recur. This is in part due to the ability of uropathogenic bacteria to invade, replicate, and persist within host epithelial cells. The biological complexity of these infections combined with a dramatic rise in antibiotic-resistant pathogens highlight the need for alternative therapies. In this review we examine current management strategies for UTIs, as well as emerging treatments, including novel compounds that block bacterial interactions with the urothelium and vaccines focused on preventing both acute and recurrent infections.

The standard recommendation for treating chronic osteomyelitis is 6 weeks of parenteral antibiotic therapy. However, oral antibiotics are available that achieve adequate levels in bone, and there are now more published studies of oral than parenteral antibiotic therapy for patients with chronic osteomyelitis. Oral and parenteral therapies achieve similar cure rates; however, oral therapy avoids risks associated with intravenous catheters and is generally less expensive, making it a reasonable choice for osteomyelitis caused by susceptible organisms. Addition of adjunctive rifampin to other antibiotics may improve cure rates. The optimal duration of therapy for chronic osteomyelitis remains uncertain. There is no evidence that antibiotic therapy for >4–6 weeks improves outcomes compared with shorter regimens. In view of concerns about encouraging antibiotic resistance to unnecessarily prolonged treatment, defining the optimal route and duration of antibiotic therapy and the role of surgical debridement in treating chronic osteomyelitis are important, unmet needs.

Background. Health care-associated pneumonia (HCAP) is prevalent among hospitalized patients. In contrast to community-acquired pneumonia (CAP), patients with HCAP are at increased risk for multidrug-resistant organisms, and appropriate initial antibiotic therapy is associated with reduced mortality. Methods. An online survey was distributed to faculty and housestaff at 4 academic medical centers. The survey required respondents to choose initial antibiotic therapy for 9 hypothetical pneumonia cases (7 cases of HCAP and 2 cases of CAP). Answers were considered correct if the antibiotic regimen chosen was consistent with published guidelines. In addition, physicians rated their knowledge of current guidelines, as well as their level of agreement with guideline recommendations. Results. Surveys were sent to 1313 physicians with a response rate of 65% (n = 855). Respondents included physicians in the following categories: hospital medicine/internal medicine, 60%; emergency medicine, 25%; and critical care, 13%. Respondents selected guideline-concordant antibiotic regimens 78% of the time for CAP, but only 9% of the time for HCAP. Because mean scores for HCAP questions were extremely low (mean, 0.63 correct answers out of 7), differences in performance between groups were too small to be meaningful. Despite their poor performance, 71% of the respondents stated that they are aware of published guidelines for HCAP, and 79% stated that they agree with and practice according to the guidelines. Conclusions. In this survey, physicians reported they were aware of, agreed with, and practiced according to published pneumonia guidelines; however, the overwhelming majority did not choose guideline-concordant therapy when tested.

During the Health Care-Associated Pneumonia Summit conducted in June 2007, it was found that there is a need for educational efforts in several areas of health care-associated infections (HAI) that extend beyond pneumonia. This supplement to Clinical Infectious Diseases represents the proceedings of the HAI Summit, a diverse panel of clinical investigators whose goal was to assess the quality of evidence regarding issues surrounding HAI and to discuss potential implications for its diagnosis and treatment in the future.

BACKGROUND Previous studies have examined the association between proton pump inhibitor (PPI) use and the risk of Clostridium difficile-associated disease (CDAD), with conflicting results. Whether outpatient PPI use influences the risk of hospital admission for CDAD among older patients who have recently been treated with antibiotics is unknown. METHODS We conducted a population-based, nested case-control study of linked health care databases in Ontario, Canada, from 1 April 2002 through 31 March 2005. We identified patients aged > or = 66 years who were hospitalized for CDAD within 60 days of receiving outpatient antibiotic therapy. Each case patient with CDAD was matched with 10 control subjects on the basis of age, sex, and details of antibiotic use (antibiotic class, timing, and number of antibiotics used). PPI use by case patients and control subjects was categorized as current (within 90 days), recent (91-180 days), or remote (181-365 days). We used conditional logistic regression to estimate the odds ratio for the association between outpatient PPI use and risk of hospitalization for CDAD. RESULTS We identified 1389 case patients and 12,303 matched control subjects. Case patients were no more likely than control subjects to have received a PPI in the preceding 90 days (adjusted odds ratio, 0.9; 95% confidence interval, 0.8-1.1). Similarly, we found no association between hospitalization for CDAD and more remote use of PPIs. CONCLUSIONS Among community-dwelling older patients, PPI use is not a risk factor for hospitalization with CDAD.

Recommendations for prolonged penicillin treatment of actinomycosis date from the early antibiotic era, when patients often presented with neglected, advanced disease and received interrupted therapy at suboptimal dosages. This report describes cases of esophageal and of cervicofacial actinomycosis treated successfully with short-term antibiotic therapy and reviews the literature. Many patients are cured with

To assess the utility of blood cultures in the management of uncomplicated pyelonephritis in women, we prospectively collected data from 583 cases. Discordant cases were defined as those for which the pathogens isolated from urine and from blood were different. We found that 97.6% of cases were nondiscordant. Clinical and microbiological evolution of infection did not differ between the 2 groups, and no changes of antibiotic therapy were required on the basis of blood culture results. Blood culture may not be routinely required for the evaluation of uncomplicated pyelonephritis in women.

We report 2 cases of serotonin syndrome and myelosuppression in bone marrow transplant recipients who received linezolid in combination with a selective serotonin reuptake inhibitor (SSRI). Given the risks to patients in this high-risk group, we recommend that this combination of medications be avoided if alternative antibiotic therapy is possible. If no alternative therapy is possible, prescribers should discontinue SSRI therapy and monitor these patients closely for evidence of serotonin syndrome or the development of hematological toxicity.

A 72-year-old homosexual man experienced frequent recurrences of symptomatic urinary tract infection (UTI) putatively due to the same strain of extraintestinal pathogenic Escherichia coli, despite receiving repeated courses of seemingly appropriate antibiotic therapy. Both the patient and his male sex partner were found to have fecal colonization with the strain recovered from the patient's urine, which exhibited characteristics of the E. coli O1/O2:K1:H7 clonal group (which is associated with urosepsis), whereas genetically distinct E. coli strains were recovered from a jar of petroleum jelly used by the couple during sexual activity.

We conducted a retrospective study to determine the yield of blood samples drawn for culture during the initial 72 h of antibiotic therapy given to 139 patients who were admitted to the hospital for community-acquired infections or fever. The yield of these blood cultures was predictable and rarely (in only 1 patient [0.72%]) isolated new pathogens.

spreads to bone, the risk of limb amputation, with its substantial associated morbidity and mortality, is dramatically increased [2]. Furthermore, diabetic foot osteomyelitis often requires surgical therapy and/or prolonged antibiotic therapy. Because the key to successful management is early diagnosis, making an accurate diagnosis of this entity is crucial. Unfortunately, it is also difficult. Two main issues complicate making a correct diagnosis of osteomyelitis in the diabetic foot [3]. First, as with other types of bone infection, it usually takes a couple of weeks before there is sufficient loss of

We report a case of implantable cardioverter-defibrillator infection due to Brucella melitensis and review 5 previously reported cases of Brucella infection of cardiac devices. Device removal, followed by antibiotic therapy for 6 weeks, is probably required for cure. Although rare, reports of Brucella infection of prosthetic implants and devices have increased in the past decade. Brucellosis should be considered in the differential diagnosis of cardiac device infection in patients residing in or traveling to areas of endemicity.

New understanding of the management of community-acquired pneumonia (CAP) has led to an interest in defining the optimal duration of antibiotic therapy [1]. Clearly, patients need to receive enough therapy to eradicate the etiologic pathogen and to prevent recurrence, yet not so much therapy that antibiotic resistance develops as a result of the patient being exposed to antimicrobials long after the original organism has been eliminated. It is very likely that the correct duration of therapy will vary from patient to patient, rather than being some arbitrary duration dictated by "local tribal custom" (i.e., 5, 7, 10, and 14 days seem to be popular durations, but no recommendations for 6, 9, 11, or 13 days of therapy have appeared). The clinical response depends on a variety of influences, including host factors (e.g., immune status and comorbid illness), bacteriologic factors (e.g., virulence, susceptibility to available therapies, and inoculum), disease factors (e.g., the

We report the clinical and microbiological characteristics of 11 cases of Aeromonas hydrophila infection of skin and soft tissue, and we review the English-language literature on such infections. Of our 11 patients, seven (64%) presented to the hospital between the months of May and September (inclusive). Three patients (27%) had an underlying systemic illness, and two (18%) had nosocomially acquired infection. The nine patients with community-acquired infection had all experienced antecedent trauma, and seven (78%) of these nine reported recent exposure to freshwater. All patients had clinical evidence of soft-tissue inflammation, and nine (82%) had fever. Four wounds were characterized by a foul odor. The infection was polymicrobial in nine cases (82%). Treatment included the administration of antibiotics in nine instances, but empirical antimicrobial therapy provided coverage against Aeromonas in only two cases. Ten patients required surgical management of their wounds. Posttraumatic wound infections with a history of freshwater exposure should alert the clinician to the possible presence of A. hydrophila. Prompt surgical evaluation of wounds in combination with appropriate antibiotic therapy is recommended for the management of these infections.

Although the traditional management of spinal epidural abscesses includes antibiotic therapy and surgical drainage, numerous reports have appeared in the literature that describe a nonsurgical approach. We report the successful nonsurgical management of a case of an extensive spinal epidural abscess in which the patient was closely monitored by serial studies with magnetic resonance imaging. Review of the literature from 1970 to 1990 revealed 37 cases that describe conservative management of spinal epidural abscesses. Despite successful conservative management reported for some cases, sudden neurological deterioration of patients receiving appropriate antibiotic therapy has also occurred. A true index of the success of nonsurgical therapy is difficult to discern since cases may have been selectively reported and unsuccessful attempts at conservative management may have never been reported once a laminectomy was performed. A prospective investigation that includes clearly defined indications for conservative management vs. surgical intervention and that can be studied with an intention-to-treat analysis is needed.

Enterobacter has emerged as an important human pathogen, particularly in sick, hospitalized patients. Previous reports of nonepidemic enterobacter bacteremia have focused on adult patients. In this report, the epidemiologic factors, clinical characteristics, treatment, and outcome for 33 patients with enterobacter bacteremia in a large children's hospital during a 5-year period are reviewed. The ratio of males to females was 1.2:1. The patients' ages ranged from 2 days to 24 years, and 18 patients were less than 18 months old. Twenty-two cases were nosocomially acquired; six were polymicrobial in nature. Significantly underlying conditions were present in 32 patients. The biliary tract and central venous catheters were the most common sources of bacteremia. Two-thirds of patients had preceding antibiotic therapy. The overall mortality was 24%; mortality attributable to enterobacter bacteremia was 18%. Statistically significant differences in mortality were associated with an age less than 18 months (P = .031) or thrombocytopenia (P = .017); presence of fever was of borderline significance (P = .098). Enterobacter bacteremia is an important cause of morbidity and mortality in pediatric patients.

A reply to Soman R, Gupta N, Shetty A, Rodrigues C. Are prolonged/continuous infusions of β-lactams for all? Clin Infect Dis 2013;57:323.

Oerskovia species, once thought to be nocardiform-like bacteria, have been only rarely associated with human infection. In this report we describe a case of central venous catheter-associated infection that was successfully treated with antibiotics. With the increased use of indwelling devices, these organisms may be more commonly recognized causes of infection. Appropriate antibiotic therapy appears to successfully treat oerskovia infection and may decrease the need for removal of some indwelling access devices.

We report three cases of cholangitis caused by Stenotrophomonas maltophilia and review two other cases reported in the literature. All five episodes occurred in patients with hepatobiliary malignancy complicated by biliary tract obstruction. All five episodes occurred in patients with hepatobiliary malignancy complicated by biliary tract obstruction. All patients had undergone biliary tract instrumentation. Before infection developed, four of the five patients had received therapy with antibiotics that do not have in vitro activity against this organism. Four patients responded to appropriate antibiotic therapy and biliary tract decompression, whereas the fifth patient, who had persistent biliary obstruction, did not respond to appropriate antibiotic therapy.

Reimbursement policies of third-party payers, including Medicare, reflect a variety of coverage patterns. For a limited group of Medicare patients who are, in Medicare terms, confined to home and require skilled and intermittent care, Medicare Part A covers home care services deemed medically necessary by a physician. Medical equipment and supplies may be included under this coverage. Medicare Part B covers physician services, laboratory tests, and drugs used by out-patients. The latter must be administered directly by a physician or by an employee of a physician with direct supervision by a physician. These restrictions have, in general, prevented reimbursement by Medicare for iv antibiotic therapy in the home. Medicaid, Blue Cross/Blue Shield, various commercial insurers, and health maintenance organizations usually cover iv antibiotics, but in many cases prior approval is necessary for coverage.