Nitrofurantoin remains a key oral antibiotic stewardship program (ASP) option in the treatment of acute uncomplicated cystitis (AUC) due to multi-drug resistant (MDR) Gram negative bacilli (GNB). However, there have been concerns regarding decreased nitrofurantoin efficacy with renal insufficiency. In our experience over the past three decades, nitrofurantoin has been safe and effective in treating AUC in hospitalized adults with renal insufficiency. Accordingly, we retrospectively reviewed our recent experience treating AUC in hospitalized adults with decreased renal function (CrCl < 60 ml/min) with nitrofurantoin. Excluded were complicated urinary tract infections. Urinary isolated susceptibility testing was done by micro broth dilution (MBD). Treatment duration was 5-7 days. Cure was defined as eradication of the uropathogen and failure was defined as minimal/no decrease in urine colony counts. Of 26 evaluable patients with renal insufficiency (CrCl < 60 ml/min), nitrofurantoin eradicated the uropathogen in 18/26 (69%) of patients, and failed in 8/26 (31%). Of the eight failures, five were due to intrinsically resistant uropathogens, e.g., Proteus sp., and one failure was related to an alkaline urine. Of the treatment failures, only two were due to renal insufficiency, i.e., CrCl < 30 ml/min. Since there are few oral antibiotics available to treat AUC due to MDR GNB uropathogens, these results have important ASP implications. Currently, nitfurantoin is not recommended if CrCl < 60 ml/min. In our experience, used appropriately against susceptible uropathogens, nitrofurantoin was highly effective in nearly all patients with CrCl = 30-60 ml/min., and only failed in two patients due to renal insufficiency (CrCl < 30 ml/ml).
Background: Bacteremia and sepsis are significant contributors to the morbidity, mortality, and economic burden of health care systems worldwide. Procalcitonin has been identified as a potentially useful marker of disease and severity in sepsis. However, the assumption that greater procalcitonin levels correlate with greater burden of disease has not been adequately studied. Methods: A retrospective chart review of adult patients admitted to an urban teaching hospital with suspected sepsis was undertaken to test the association of elevated procalcitonin (>30 ng/mL) with other markers of sepsis (lactic acid, white blood cell count, percent bands), severity of disease (Sequential Organ Failure Assessment [SOFA] and Acute Physiology and Chronic Health Evaluation–II [APACHE II] scores), and mortality. Results: In total, 168 patients were identified over 18 months (42% ward, 11% Stepdown, 44% medical intensive care unit [MICU], 2% surgical intensive care unit (STICU), 1% gynecology [GYN]). The Spearman correlation analysis showed that serum procalcitonin level did not correlate with SOFA ( P = .238) or APACHE II ( P = .918) scores on admission, and did not correlate with survival (Kruskal-Wallis test, P = .937). However, higher serum procalcitonin levels were associated with patients who had positive blood cultures (Kruskal-Wallis test, P = .0016 for Gram-positive and P = .0007 for Gram-negative bacteria). Lactic acid levels on admission strongly correlated with SOFA APACHE II (the Spearman correlation, P < .0001 for both) and mortality ( P = .0001 for both). Conclusions: Higher serum procalcitonin levels above 30 ng/mL failed to correlate with indicators of sepsis, severity of disease (SOFA and APACHE II scores), and mortality but were associated with positive blood cultures. Lactic acid levels did show correlation to both severity of disease and mortality. Serum procalcitonin levels >30 ng/mL do not appear to correlate with the severity of disease in a sample of patients with markedly elevated initial procalcitonin levels.
Background The 2019 ATS/IDSA community-acquired pneumonia (CAP) guidelines recommend to abandon the term healthcare-associated pneumonia (HCAP) and to base the use of broad-spectrum antibiotics on local epidemiology and risk factors. Jamaica, NY represents a unique population of ethnically diverse, largely immigrant patients. Several nursing homes, an international airport, along with a low socioeconomic status population feed into the hospital. The purpose of this study is to determine prevalent risk factors for drug-resistant pathogens (DRP) in CAP within an urban population. The secondary objective is to validate the Drug Resistance in Pneumonia (DRIP) score in this population. Methods A retrospective study was conducted on adults admitted from August 2018-December 2019 with a diagnosis of CAP, including aspiration pneumonia. Patients with a DRP respiratory culture (collected within 48 hours of admission) were selected, the next consecutively admitted patient with a non-resistant culture was included as a control. Results A total of 227 patients were included (114 in the DRP group and 113 in the control group). The DRP group had more patients with tracheostomies (30% vs 3%, p < .001) and chronic pulmonary disease (37% vs 16%, p < .001) (Table 1). Approximately 40% of the DRP patients were admitted from a long term care (LTC) facility compared to 8.8% in the control group (p < .001). Isolation of P. aeruginosa was not associated with LTC residence (Odds Ratio: 0.75) in our population (Table 2). All DRIP score components were associated with the isolation of DRP in our patient population, except for methicillin-resistant S. aureus (MRSA) colonization (Table 3). In our population 50% of the DRP had a DRIP score < 3. DRIP scores > 2, > 3 and > 4 had low negative predictive values (NPV) for the isolation of DRP in CAP (71.9%, 67.4% and 64.2%, respectively). Conclusion Demographic risk factors may exist for DRP in CAP, e.g. tracheostomy, pulmonary disease. Using a DRIP score cut off of > 4 missed 50% of the DRP in our study population. Despite a DRIP score > 4 having a specificity of 90.3%, with a NPV of 64.2% this scoring tool may underestimate the prevalence of DRP in our patient population. Based on our findings, institutions should consider local validation of the DRIP score prior to implementing use at their site. Disclosures All Authors: No reported disclosures.
Background Based on the RECOVERY trial, the NIH strongly recommends systemic corticosteroids for COVID-19 pneumonia with hypoxia. The study demonstrated reduced 28-day mortality after dexamethasone 6mg daily for up to 10 days compared to SOC alone. In practice, physicians may continue therapy for longer periods if potential benefit outweighs potential risk. Little is known about adverse events associated with prolonged corticosteroid use in patients with COVID-19; however, in general, this can increase risk for bacterial or fungal infections. This study aimed to explore the incidence of secondary infections during extended corticosteroid use for COVID-19. Methods A retrospective study was performed in adults at two community hospitals between September 2020 and May 2021 with a diagnosis of respiratory failure secondary to COVID-19 infection. Those with at least one new, laboratory-confirmed secondary infection during hospitalization after at least 10 cumulative days of corticosteroids were included. Demographic characteristics, clinical data and outcomes were extracted from the medical records. Quantitative analyses was performed using SPSS v27.0 and R. Results Of over 1,500 COVID-19 admissions within the timeframe, 73 patients met inclusion criteria (Table 1). No patient received immunomodulators for COVID-19 treatment. Patients had a median of 18 days on corticosteroids (range 10-65 days) prior to first positive culture. There were 130 positive cultures identified in blood, urine, and sputum samples (Figure 1), including polymicrobical cultures, yielding 34 clinically relevant organisms (Table 2). Hospital course was complicated by septic shock (68.5%), worsening of lung function (76.7%), and acute organ damage (57.5%); 55 (75%) patients expired during index admission. Conclusion Patients with COVID-19 on extended courses of corticosteroids have relatively higher rates of clinically significant invasive secondary infections and associated poor outcomes. Given there is limited information suggesting improved outcomes with these prolonged courses, risk to benefit analysis must be considered when deciding whether to extend corticosteroid treatment for more than 10 days for COVID-19. Disclosures All Authors: No reported disclosures.
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