OBJECTIVES: To evaluate the rate of discordance between patients and physicians on adherence to highly active antiretroviral therapy (HAART) and identify factors related to discordance in these two ...assessments.
DESIGN: Prospective, multicenter, cohort study (AdICONA) nested within the Italian Cohort Naïve Antiretrovirals (ICONA) study.
SETTING: Tertiary clinical centers.
PARTICIPANTS: The patients filled out a 16‐item self‐administered questionnaire on adherence to HAART. At the same time, physicians estimated the current HAART adherence of their patient.
MAIN OUTCOME MEASURE: Discordance between patient and physician on adherence to antiretroviral therapy.
RESULTS: From May 1999 to March 2000, 320 paired patient‐physician assessments were obtained. Patients had a mean plasma HIV RNA of 315 copies/ml (64% had undetectable HIV RNA) and a mean CD4+ cell count of 577 cells × 106/L. Nonadherence was reported by 30.9% of patients and estimated by physicians in 45.0% cases. In 111 cases (34.7%), patients and physicians were discordant on adherence to HAART. Kappa statistics was 0.27. Using patient‐assessed adherence as reference, sensitivity, specificity, positive predictive value, and negative predictive value of physician‐estimated adherence were 64.7%, 66.6%, 81.2%, and 45.8%, respectively. On multivariable analysis, low education level, unemployment, absence of a social worker in the clinical center, and unavailability of afternoon visits were significantly correlated with patient‐physician discordance on adherence to antiretrovirals.
CONCLUSIONS: Physicians did not correctly estimate patient‐reported adherence to HAART in more than one third of patients. Both social variables and factors related to the clinical center were important predictors of discordance between patients and physicians. Interventions to enhance adherence should include strategies addressed to improve patient‐physician relationship.
Purpose
SARS-COV-2 pandemic led to antibiotic overprescription and unprecedented stress on healthcare systems worldwide. Knowing the comparative incident risk of bloodstream infection due to ...multidrug-resistant pathogens in COVID ordinary wards and intensive care-units may give insights into the impact of COVID-19 on antimicrobial resistance.
Methods
Single-center observational data extracted from a computerized dataset were used to identify all patients who underwent blood cultures from January 1, 2018 to May 15, 2021. Pathogen-specific incidence rates were compared according to the time of admission, patient’s COVID status and ward type.
Results
Among 14,884 patients for whom at least one blood culture was obtained, a total of 2534 were diagnosed with HA-BSI. Compared to both pre-pandemic and COVID-negative wards, HA-BSI due to
S. aureus
and
Acinetobacter
spp
.
(respectively 0.3 95% CI 0.21–0.32 and 0.11 0.08–0.16 new infections per 100 patient-days) showed significantly higher incidence rates, peaking in the COVID-ICU setting. Conversely,
E. coli
incident risk was 48% lower in COVID-positive vs COVID-negative settings (IRR 0.53 0.34–0.77). Among COVID + patients, 48% (
n
= 38/79) of
S. aureus
isolates were resistant to methicillin and 40% (
n
= 10/25) of
K. pneumoniae
isolates were resistant to carbapenems.
Conclusions
The data presented here indicate that the spectrum of pathogens causing BSI in ordinary wards and intensive care units varied during the pandemic, with the greatest shift experienced by COVID-ICUs. Antimicrobial resistance of selected high-priority bacteria was high in COVID positive settings.
To analyse the virological and clinical efficacy of cidofovir combined with highly active antiretroviral therapy (HAART) in AIDS-related progressive multifocal leukoencephalopathy (PML).
Multicentre ...observational study of consecutive HIV-positive patients with histologically or virologically-proven PML. Group A, 26 patients treated with HAART; group B, 14 patients treated with HAART plus cidofovir 5 mg/kg intravenously per week for the first 2 weeks and alternate weeks thereafter. JC virus DNA was quantified in cerebrospinal fluid (CSF) by PCR.
Baseline virological, immunological and clinical characteristics were homogeneous between the groups. In one case cidofovir was discontinued because of severe proteinuria. There was no significant difference in HIV RNA responses and changes in the number of CD4 cells between group A and B. After 2 months of therapy, five out of 12 (42%) patients from group A and seven out of eight (87%) from group B reached undetectable JC virus DNA in the CSF (Chi-square P = 0.04); moreover, 24% of group A and 57% of group B patients showed neurological improvement or stability (P = 0.038). One-year cumulative probability of survival was 0.67 with cidofovir and 0.31 without (log-rank test, P = 0.01). Variables independently associated with longer survival were the use of cidofovir, HAART prior to the onset of PML, a baseline JC virus DNA load in CSF < 4.7 log10 copies/ml, and a baseline Karnofsky performance status > or = 60.
In AIDS-related PML, cidofovir added to HAART is associated with a more effective control of JCV replication, with improved neurological outcome and survival compared with HAART alone.
•Candidemia is a high-mortality disease, keystone of antifungal stewardship programs.•Clinical management includes both therapeutic and non-therapeutic aspects of care.•A systematic clinical ...management is difficult to achieve in clinical practice.•An appropriate and systematic clinical approach to candidemia improves survival.
Taking into account the significant morbidity, mortality, and hospital costs related to Candidemia, our objective is to define if improving appropriateness in candidemia management was associated with better clinical outcomes.
A prospective observational monocentric cohort study was conducted. Adherence to five main elements was examined: appropriate selection of initial therapy; follow-up blood culture; echocardiography; ophthalmological examination; and removal of a central venous catheter. The correlation between the number of appropriate elements achieved and 30 day survival was examined.
Patients with candidemia (n = 213) were enrolled. Adherence to all five elements was achieved in 36 cases (16.9%), while the majority adhered to three or four elements (28.2% and 37.1%, respectively). Multivariable Cox regression analysis revealed that the number of elements achieved was associated with survival HR: 0.39 (0.30–0.52); p < 0.001. Also, the number of elements achieved correlated positively with duration of therapy (p = 0.01), but not length of hospital stay (p = 0.56).
Five elements, including therapeutic and non-therapeutic-related aspects, of care were good indicators of appropriate management of patients with candidemia. Implementation of evidence-based practice regarding optimal clinical management is crucial for any antimicrobial stewardship program.
Abstract
Objectives
To assess the impact of piperacillin/tazobactam MICs on in-hospital 30 day mortality in patients with third-generation cephalosporin-resistant Escherichia coli bloodstream ...infection treated with piperacillin/tazobactam, compared with those treated with carbapenems.
Methods
A multicentre retrospective cohort study was conducted in three large academic hospitals in Italy between 2018 and 2022. The study population comprised patients with monomicrobial third-generation cephalosporin-resistant E. coli bloodstream infection, who received either piperacillin/tazobactam or carbapenem therapy within 48 h of blood culture collection. The primary outcome was in-hospital 30 day all-cause mortality. A propensity score was used to estimate the likelihood of receiving empirical piperacillin/tazobactam treatment. Cox regression models were performed to ascertain risk factors independently associated with in-hospital 30 day mortality.
Results
Of the 412 consecutive patients included in the study, 51% received empirical therapy with piperacillin/tazobactam, while 49% received carbapenem therapy. In the propensity-adjusted multiple Cox model, the Pitt bacteraemia score HR 1.38 (95% CI, 0.85–2.16) and piperacillin/tazobactam MICs of 8 mg/L HR 2.35 (95% CI, 1.35–3.95) and ≥16 mg/L HR 3.69 (95% CI, 1.86–6.91) were significantly associated with increased in-hospital 30 day mortality, while the empirical use of piperacillin/tazobactam was not found to predict in-hospital 30 day mortality HR 1.38 (95% CI, 0.85–2.16).
Conclusions
Piperacillin/tazobactam use might not be associated with increased mortality in treating third-generation cephalosporin-resistant E. coli bloodstream infections when the MIC is <8 mg/L.
The Fungitell assay (FA) and the Wako beta-glucan test (GT) are employed to measure the serum/plasma 1,3-beta-D-glucan (BDG), a well-known invasive fungal disease biomarker. Data to convincingly ...and/or sufficiently support the GT as a valuable alternative to the FA are yet limited. In this study, we evaluated the FA and the GT to diagnose invasive aspergillosis (IA), invasive candidiasis (IC), and Pneumocystis jirovecii pneumonia (PJP). The FA and GT performances were compared in sera of patients with IA (n = 40), IC (n = 78), and PJP (n = 17) with respect to sera of control patients (n = 187). Using the manufacturer's cutoff values of 80 pg/mL and 11 pg/mL, the sensitivity and specificity for IA diagnosis were 92.5% and 99.5% for the FA and 60.0% and 99.5% for the GT, respectively; for IC diagnosis were 100.0% and 97.3% for the FA and 91.0% and 99.5% for the GT, respectively; for PJP diagnosis were 100.0% and 97.3% for the FA and 88.2% and 99.5% for the GT, respectively. When an optimized cutoff value of 7.0 pg/mL for the GT was used, the sensitivity and specificity were 80.0% and 97.3% for IA diagnosis, 98.7% and 97.3% for IC diagnosis, and 94.1% and 97.3% for PJP diagnosis, respectively. At the 7.0-pg/mL GT cutoff, the agreement between the assays remained and/or became excellent for IA (95.1%), IC (97.3%), and PJP (96.5%), respectively. In conclusion, we show that the GT performed as well as the FA only with a lowered cutoff value for positivity. Further studies are expected to establish the equivalence of the two BDG assays.
OBJECTIVECOVID-19 pandemic has changed in-hospital care and was linked to superimposed infections. Here, we described epidemiology and risk factors for hospital-acquired bloodstream infections ...(HA-BSIs), before and during COVID-19 pandemic.METHODSThis retrospective, observational, single-center real-life study included 14,884 patients admitted to hospital wards and intensive care units (ICUs) with at least one blood culture, drawn 48 h after admission, either before (pre-COVID, N = 7382) or during pandemic (N = 7502, 1203 COVID-19+ and 6299 COVID-19-).RESULTSTwo thousand two hundred and forty-five HA-BSI were microbiologically confirmed in 14,884 patients (15.1%), significantly higher among COVID-19+ (22.9%; ptrend < .001). COVID-19+ disclosed a significantly higher mortality rate (33.8%; p < .001) and more ICU admissions (29.7%; p < .001). Independent HAI-BSI predictors were: COVID-19 (OR: 1.43, 95%CI: 1.21-1.69; p < .001), hospitalization length (OR: 1.04, 95%CI: 1.03-1.04; p < .001), ICU admission (OR: 1.38, 95%CI: 1.19-1.60; p < .001), neoplasms (OR:1.48, 95%CI: 1.34-1.65; p < .001) and kidney failure (OR: 1.81, 95%CI: 1.61-2.04; p < .001). Of note, HA-BSI IRs for Acinetobacter spp. (0.16 × 100 patient-days) and Staphylococcus aureus (0.24 × 100 patient-days) peaked during the interval between first and second pandemic waves in our National context.CONCLUSIONSPatients with HA-BSI admitted before and during pandemic substantially differed. COVID-19 represented a risk factor for HA-BSI, though not confirmed in the sole pandemic period. Some etiologies emerged between pandemic waves, suggesting potential COVID-19 long-term effect on HA-BSIs.
PDF
