Both aerosol AmBd and ABLC appear to be associated with a low rate of invasive pulmonary fungal infection in the early posttransplant period. Patients receiving ABLC were less likely to experience a treatment-related adverse event.

No abstract

Aerosolized delivery of antimicrobial agents is an attractive option for management of pulmonary infections, as this is an ideal method of providing high local drug concentrations while minimizing systemic exposure. With the paucity of consensus regarding the safety, efficacy, and means with which to use aerosolized antimicrobials, a task force was created by the Society of Infectious Diseases Pharmacists to critically review and evaluate the literature on the use of aerosolized antiinfective agents. This article summarizes key findings and statements for preventing or treating a variety of infectious diseases, including cystic fibrosis, bronchiecstasis, hospital-acquired pneumonia, fungal infections, nontuberculosis mycobacterial infection, and Pneumocystis jiroveci pneumonia. Our intention was to provide guidance for clinicians on the use of aerosolized antibiotics through evidence-based pharmacotherapy. Further research with well-designed clinical trials is necessary to elucidate the optimal dosage and duration of therapy and, of equal importance, to appreciate the true risks associated with the use of aerosolized delivery systems.

Positive outcomes of antimicrobial stewardship programs in the inpatient setting have been well documented, but the benefits for patients not admitted to the hospital remain less clear. This report describes a retrospective case-control study of patients discharged from the ED with subsequent positive cultures conducted to determine if integrating antimicrobial stewardship responsibilities into practice of the dedicated emergency medicine clinical pharmacist (EPh) decreased times to positive culture follow-up, patient or primary care provider (PCP) notification, and appropriateness of empiric or final antimicrobial therapy for patients discharged from the emergency department (ED). Pre-and post-implementation groups of an EPh-managed antimicrobial stewardship program were compared. Data were collected from medical records and the ED culture database. Continuous data were analyzed using Wilcoxon Rank Sum test and categorical data using Chi-squared analysis. Positive cultures were identified in 177 patients, 104 and 73 in pre and post-implementation groups, respectively. Median time to culture review in the pre-implementation group was 3 days (range 1–15) and 2 days (range 0–4) in the post-implementation group (p=0.0001). There were positive cultures that required notification in 74 (71.2%) and 36 (49.3%) on pre- and post-implementation groups, respectively. Median time to patient or PCP notification was 3 days (range 1–9) in the pre-implementation group and 2 days(range 0–4) in the Eph managed program (p = 0.01). No difference in appropriate antimicrobial therapy was seen.

Treatment of patients with invasive fungal infections was associated with a significantly higher inpatient hospital cost compared with controls. However, due to new diagnostic techniques and effective antifungal therapy, the relative cost of these infections appears to be at least stable compared with the previous decade. These findings can help assess the utility of cost-avoidance strategies such as antifungal prophylaxis and application of appropriate treatment.

Therapeutic drug monitoring (TDM), an established practice for many antimicrobials, has recently seen increasing utilization in the management of patients receiving antifungal agents. There is a growing body of literature supporting the use of TDM for itraconazole, voriconazole, posaconazole, and flucytosine. In addition, clinical practice guidelines have been recently published that give recommendations on the appropriate use of TDM for antifungal agents. However, there are still uncertainties regarding the optimal use of antifungal TDM in clinical practice. We conducted a review of recent literature in order to describe the clinical situations and specific antifungal agents for which TDM is ideal and summarize key information about the pharmacokinetics, pharmacodynamics, drug toxicities, TDM concentration targets, and dose adjustment algorithms for antifungals in which routine TDM is performed.

The media have a key role in communicating advances in medicine to the general public, yet the accuracy of medical journalism is an under-researched area. This project adapted an established monitoring instrument to analyse all identified news reports (n = 312) on a single medical research paper: a meta-analysis published in the British Journal of Cancer which showed a modest link between processed meat consumption and pancreatic cancer. Our most significant finding was that three sources (the journal press release, a story on the BBC News website and a story appearing on the ‘NHS Choices’ website) appeared to account for the content of over 85% of the news stories which covered the meta analysis, with many of them being verbatim or moderately edited copies and most not citing their source. The quality of these 3 primary sources varied from excellent (NHS Choices, 10 of 11 criteria addressed) to weak (journal press release, 5 of 11 criteria addressed), and this variance was reflected in the accuracy of stories derived from them. Some of the methods used in the original meta-analysis, and a proposed mechanistic explanation for the findings, were challenged in a subsequent commentary also published in the British Journal of Cancer, but this discourse was poorly reflected in the media coverage of the story.

A 64-year-old male with Aspergillus fumigatus infection that had disseminated from the lung to the ankle and adjacent bone was treated successfully with posaconazole after therapy with itraconazole and amphotericin B lipid complex failed. Marked clinical improvement occurred within 6 weeks of initiation of posaconazole therapy; after 6 months, infection had resolved at all sites. The patient has had no recurrence of infection. CASE REPORTA 64-year-old man underwent a bilateral lung transplant for chronic obstructive pulmonary disease. Ten months following the transplant, the patient received antithymocyte globulin treatment for rejection. Because Aspergillus flavus and Aspergillus fumigatus were recovered from bronchoscopic lavage fluid samples obtained at the time of rejection, inhaled amphotericin B deoxycholate (AmB), 25 mg once weekly, was initiated as prophylaxis. Five months later, the patient came to the transplant clinic with complaints of increased shortness of breath, fever, and a swollen, painful right ankle (Fig. 1). He denied trauma to the ankle. His immunosuppressive regimen consisted of azathioprine, prednisone, and tacrolimus. The chest radiograph showed a loculated right-side pleural effusion. Bronchoscopy was also performed, and examination of the lavage fluid with potassium hydroxide (KOH) revealed septate hyaline hyphae. Empirical oral itraconazole solution (200 mg every 12 h) was started, and inhaled AmB therapy was continued. The culture subsequently grew A. fumigatus.Because of persistent fever and right ankle swelling and pain, the patient was admitted to the hospital 7 days later. Relevant laboratory results on admission included a leukocyte count of 12.6 ϫ 10 9 /mm 3 , a platelet count of 370,000 ϫ 10 9 / mm 3 , a blood urea nitrogen level of 30 mg/dl, a serum creatinine level of 1.2 mg/dl, a sedimentation rate of 75 mm/h, a uric acid level of 5.5 mg/dl, and liver function test results within normal limits. Computed tomography of the chest confirmed the presence of a complex, loculated, right pleural effusion that contained numerous high-density areas; a small amount of parenchymal opacity was associated with the effusion. Thoracentesis of the effusion yielded pleural fluid with a pH of 7.02, protein level of 2.7 g/dl, and glucose level of Ͻ20 mg/dl. KOH examination of the pleural fluid revealed septate hyaline hyphae; the corresponding cultures grew A. fumigatus. Magnetic resonance imaging (MRI) of the right foot and ankle at this time revealed moderate ankle effusion and extensive signal abnormality throughout the majority of the calcaneal bone. There was sparing of the anterior process, but superior lateral calcaneal cortical destruction was noted. Arthrocentesis of the right ankle revealed septate hyaline hyphae on KOH examination, and the culture subsequently grew A. fumigatus. MRI of the brain showed no lesions.At this time, systemic amphotericin B lipid complex (ABLC; 5 mg/kg/day) was added to his antifungal regimen. Although itraconazole treatment was continued initially, it was...