Short courses of antibiotic therapy yield similar clinical outcomes as prolonged courses of antibiotic therapy for Enterobacteriaceae bacteremia, and may protect against subsequent MDRGN bacteria.

IMPORTANCE Conversion to oral therapy for Enterobacteriaceae bacteremia has the potential to improve the quality of life of patients by improving mobility, eliminating catheterassociated discomfort, decreasing the risk for noninfectious and infectious catheterassociated adverse events, and decreasing health care costs. OBJECTIVE To compare the association of 30-day mortality with early oral step-down therapy vs continued parenteral therapy for the treatment of Enterobacteriaceae bloodstream infections. DESIGN, SETTING, AND PARTICIPANTS This retrospective multicenter cohort study included a 1:1 propensity score-matched cohort of 4967 unique patients hospitalized with monomicrobial Enterobacteriaceae bloodstream infection at 3 academic medical centers from January 1, 2008, through December 31, 2014. Eligibility criteria included appropriate source control measures, appropriate clinical response by day 5, active antibiotic therapy from day 1 until discontinuation of therapy, availability of an active oral antibiotic option, and ability to consume other oral medications or feeding. Statistical analysis was performed from March 2, 2018, to June 2, 2018. EXPOSURES Oral step-down therapy within the first 5 days of treatment of Enterobacteriaceae bacteremia. MAIN OUTCOMES AND MEASURES The main outcome was 30-day all-cause mortality. RESULTS Of the 2161 eligible patients, 1185 (54.8%) were male and 1075 (49.7%) were white; the median (interquartile range [IQR]) age was 59 (48-68) years. One-to-one propensity-score matching yielded 1478 patients, with 739 in each study arm. Sources of bacteremia included urine (594 patients [40.2%]), gastrointestinal tract (297 [20.1%]), central line-associated (272 [18.4%]), pulmonary (58 [3.9%]), and skin and soft tissue (41 [2.8%]). There were 97 (13.1%) deaths in the oral step-down group and 99 (13.4%) in the intravenous (IV) group within 30 days (hazard ratio [HR], 1.03; 95% CI, 0.82-1.30). There were no differences in recurrence of bacteremia within 30 days between the groups (IV, 6 [0.8%]; oral, 4 [0.5%]; HR, 0.82 [0.33-2.01]). Patients transitioned to oral step-down therapy were discharged from the hospital an average of 2 days (IQR, 1-6) sooner than patients who continued to receive IV therapy (5 days [IQR, 3-8 days] vs 7 days [IQR, 4-14 days]; P < .001). CONCLUSIONS AND RELEVANCE In this study, 30-day mortality was not different among hospitalized patients who received oral step-down vs continued parenteral therapy for the treatment of Enterobacteriaceae bloodstream infections. The findings suggest that transitioning to oral step-down therapy may be an effective treatment approach for patients with Enterobacteriaceae bacteremia who have received source control and demonstrated an appropriate clinical response. Early transition to oral step-down therapy may be associated with a decrease in the duration of hospital stay for patients with Enterobacteriaceae bloodstream infections.

Pathway implementation has a limited direct impact on LOS in relatively low-volume procedures such as laryngectomy. Although pathways may influence utilization trends, their impact is likely mediated by the development and educational process that accompanies pathway adoption rather than implementation of the pathway itself. The inclusion of temporal trends and contemporary cohorts provides substantial insight into the effectiveness of critical pathways.

Latinos in the U.S. are disproportionately affected by HIV and are at risk for late presentation to care. Between June 2011 and January 2012, we conducted a cross-sectional survey of 209 Baltimore Latinos at community-based venues to evaluate the feasibility of using communication technology (ICT)-based interventions to improve access to HIV testing and education within the Spanish-speaking community in Baltimore. Participants had a median age of 33 years (IQR 28-42), 51.7% were male, and 95.7% were foreign-born. Approximately two-thirds (63.2%) had been in the U.S. less than 10 years and 70.1% had been previously tested for HIV. Cell phone (92.3%) and text messaging (74.2%) was used more than Internet (52.2%) or e-mail (42.8%) (p<0.01). In multivariate analysis, older age and lower education were associated with less utilization of Internet, e-mail and text messaging, but not cell phones. Interest was high for receiving health education (73.1%), HIV education (70.2%), and test results (68.8%) via text messaging. Innovative cell phone-based communication interventions have the potential to link Latino migrants to HIV prevention, testing and treatment services.

BackgroundThe recommended duration of antibiotic treatment for Enterobacteriaceae bacteremia is between 7 and 14 days. We compared the clinical outcomes of patients receiving short-course (6–10 days) vs prolonged-course (11–15 days) antibiotic therapy for Enterobacteriaceae bacteremia.MethodsA retrospective cohort study was conducted at The Johns Hopkins Hospital, The University of Maryland Medical Center, and The Hospital of the University of Pennsylvania including patients with monomicrobial Enterobacteriaceae bacteremia treated with in vitro active antibiotic therapy in the range of 6–15 days between 2008 and 2014. 1:1 nearest neighbor propensity score matching without replacement was performed, prior to regression analysis, to estimate the risk of all-cause mortality within 30 days after the end of antibiotic treatment for patients receiving short vs. prolonged durations of antibiotic therapy. Secondary outcomes included Clostridium difficile infection (CDI) and the emergence of multidrug-resistant Gram-negative (MDRGN) bacteria within 30 days after the end of antibiotic therapy.ResultsA total of 1,769 patients met eligibility criteria. There were 385 matched pairs who were well-balanced on baseline characteristics. The median duration of therapy in the short-course group and prolonged-course group was 8 days (interquartile range (IQR) 7–9 days) and 15 days (IQR 13–15 days), respectively. No difference in all-cause mortality between short- and prolonged-course treatment groups was observed (adjusted hazard ratio [aHR] 1.00; 95% CI 0.62–1.63). Rates of CDI were similar between the treatment groups (OR 1.17; 95% CI 0.39–3.51). There was a non-significant protective effect of short-course antibiotic therapy on the emergence of MDRGN bacteria (OR 0.59; 95% CI 0.32–1.09 P = 0.09).ConclusionShort courses of antibiotic therapy yields similar clinical outcomes to prolonged courses of antibiotic therapy for Enterobacteriaceae bacteremia, and may protect against subsequent MDRGN emergence.Disclosures All authors: No reported disclosures.

Introduction The Infectious Diseases Society of America guidelines recommend either 14 days of trimethoprim-sulfamethoxazole (TMP-SMX) or 7 days of ciprofloxacin for the treatment of pyelonephritis. Antibiotic courses of 7 days of TMP-SMX versus 7 days of ciprofloxacin for pyelonephritis have not been previously compared. We evaluated the odds of a subsequent, symptomatic urinary tract infection (UTI) for women with E. coli pyelonephritis receiving a 7-day course of TMP-SMX versus a 7-day course of ciprofloxacin. Methods Women ages 16 and older with Escherichia coli pyelonephritis presenting to 5 healthcare facilities in the greater Maryland area between 2010 and 2016 receiving either TMP-SMX or ciprofloxacin were included. Patients were excluded if they met any of the following criteria: (a) pregnancy, (b) dialysis dependency, (c) E. coli not susceptible to the treatment prescribed, (d) polymicrobial urine culture, or (e) greater than 48 hours of antibiotic therapy other than TMP-SMX or ciprofloxacin. Results Of 272 women meeting eligibility criteria, 81 (30%) and 191 (70%) received 7 days of TMP-SMX and 7 days of ciprofloxacin, respectively. In an adjusted model, the likelihood of a recurrent UTI within 30 days for the TMP-SMX and ciprofloxacin groups was similar (aOR: 2.30, 95% confidence interval: 0.72–7.42). Conclusions Our findings suggest that 7 days of TMP-SMX therapy may result in similar clinical outcomes compared with 7 days of ciprofloxacin for the treatment of pyelonephritis. Considering the frequency of pyelonephritis and risks of antibiotic resistance and associated toxicities, decreasing the duration of antibiotic therapy for pyelonephritis may impact a large number of women.

Checkpoint inhibitor immunotherapy has revolutionised cancer treatment since its inception. During an inflammatory response, activated cytotoxic T cells expressing programmed cell death protein 1 (PD-1) interact with programmed cell death-ligand 1 (PD-L1) on peripheral tissues to thwart an autoimmune reaction. Cancer cells upregulate PD-L1 expression to evade the immune system and are vulnerable to attack in the presence of PD-1 or PD-L1 checkpoint inhibitors. However, blockade of this pathway also contributes to the unintended side effect of autoimmune endocrinopathies. Atezolizumab, a checkpoint inhibitor against PD-L1, is associated with the rare complication of type 1 diabetes. We present a case of glutamic acid decarboxylase antibody-positive type 1 diabetes developing in a patient with a long-standing history of well-controlled type 2 diabetes following treatment with atezolizumab for metastatic renal cell carcinoma.