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Background : Narrow-spectrum antibiotics have been found to be equivalent to anti-Pseudomonal agents in preventing organ space infections (OSI) in children with uncomplicated appendicitis. Comparative effectiveness data for children with complicated appendicitis remains limited. This investigation aimed to compare outcomes between the most common narrow-spectrum regimen (ceftriaxone with metronidazole: CM) and anti-Pseudomonal regimen (piperacillin/tazobactam: PT) used perioperatively in children with complicated appendicitis. Methods : Multicenter retrospective cohort study using clinical data from the NSQIP-Pediatric Appendectomy Collaborative database merged with antibiotic utilization data from the Pediatric Health Information System database. Mixed-effects multivariate regression was used to compare NSQIP-defined outcomes and resource utilization between treatment groups after adjusting for patient characteristics, disease severity, and clustering of outcomes within hospitals. Results : 654 patients from 14 hospitals were included, of which 37.9% received CM and 62.1% received PT. Following adjustment, patients in both groups had similar rates of OSI (CM: 13.3% vs. PT: 18.0%, OR 0.88 [95%CI 0.38, 2.03]), drainage procedures (CM: 8.9% vs. PT: 14.9%, OR 0.76 [95%CI 0.30, 1.92]), and postoperative imaging (CM: 19.8% vs. PT: 22.5%, OR 1.17 [95%CI 0.65, 2.12]). Treatment groups also had similar rates of 30-day cumulative post-operative length of stay (CM: 6.1 vs. PT: 6.0 days, RR 1.01 [95%CI 0.81, 1.25]) and hospital cost (CM: $19,235 vs. PT: $20,552, RR 0.92 [95%CI 0.69, 1.23]). Conclusions : Rates of organ space infection and resource utilization were similar in children with complicated appendicitis treated with ceftriaxone plus metronidazole and piperacillin/tazobactam.

Objectives To explore the in vitro antimicrobial susceptibility among clinically important Gram-negative bacteria (GNB) in Taiwan. Methods From 2016 through 2018, a total of 5458 GNB isolates, including Escherichia coli (n = 1545), Klebsiella pneumoniae (n = 1255), Enterobacter species (n = 259), Pseudomonas aeruginosa (n = 1127), Acinetobacter baumannii complex (n = 368), and Stenotrophomonas maltophilia (n = 179), were collected. The susceptibility results were summarized by the breakpoints of minimum inhibitory concentration (MIC) of CLSI 2020, EUCAST 2020 (for colistin), or published articles (for ceftolozane/tazobactam). The resistance genes among multidrug-resistant (MDR) or extensively drug-resistant (XDR)-GNB were investigated by multiplex PCR. Results Significantly higher rates of non-susceptibility (NS) to ertapenem and carbapenemase production, predominantly KPC and OXA-48-like beta-lactamase, were observed in Enterobacterales isolates causing respiratory tract infection than those causing complicated urinary tract or intra-abdominal infection (12.7%/3.44% vs. 5.7%/0.76% or 7.7%/0.97%, respectively). Isolates of Enterobacter species showed higher rates of phenotypic extended-spectrum β-lactamase and NS to ertapenem than E. coli or K. pneumoniae isolates. Although moderate activity (54–83%) was observed against most potential AmpC-producing Enterobacterales isolates, ceftolozane/tazobactam exhibited poor in vitro (44.7–47.4%) activity against phenotypic AmpC Enterobacter cloacae isolates. Additionally, 251 (22.3%) P. aeruginosa isolates exhibited the carbapenem-NS phenotype, and their MDR and XDR rate was 63.3% and 33.5%, respectively. Fifteen (75%) of twenty Burkholderia cenocepacia complex isolates were inhibited by ceftolozane/tazobactam at MICs of ≤4 μg/mL. Conclusions With the increase in antibiotic resistance in Taiwan, it is imperative to periodically monitor the susceptibility profiles of clinically important GNB.

BACKGROUND This article provides baseline epidemiological data on Pseudomonas spp. BSI in England for comparison against future findings from the mandatory surveillance of this infection, beginning April 2017. AIM We report trends in incidence, thirty-day all-cause mortality and antimicrobial resistance of Pseudomonas spp. BSI in England between 2009 and 2018. METHODS Patients and antibiotic susceptibility data were obtained from Public Health England's voluntary surveillance database. Mortality information was linked from a central data repository. FINDINGS There were 39,322 Pseudomonas spp. BSI between 2009 and 2018. Regression analysis found that the incidence rate was greater by 18.5% (p< 0.01) in the summer (June to August) and by 16.2% (p< 0.01) in the autumn (September to November), compared with spring (March to May). The thirty-day all-cause case fatality rate (CFR) declined from 32.0% in 2009 to 23.8% in 2018 (p

Purpose The risk of acute kidney injury (AKI) associated with concomitant vancomycin and piperacillin/tazobactam in the intensive care unit (ICU) remains controversial. The aim of this study was to compare the AKI incidence associated with concomitant vancomycin and piperacillin/tazobactam compared to either cefepime or meropenem with vancomycin in the ICU. Materials and methods A multicenter, retrospective, propensity score-matched cohort study was conducted in adult ICU patients administered vancomycin in combination with either piperacillin/tazobactam, cefepime, or meropenem were included. Patients developing AKI ≤48 h following combination therapy initiation were excluded. The primary endpoint was to compare the incidence of AKI associated with concomitant antimicrobial therapy. Multivariable Cox regression modeling in predicting AKI was also conducted. Results A total of 1044 patients were matched. The AKI incidence in vancomycin- piperacillin/tazobactam and vancomycin-cefepime/meropenem groups were 21.9% and 16.8%, respectively (p = 0.068). Multivariable prediction models showed concomitant vancomycin-piperacillin/tazobactam was an independent risk factor of AKI using serum creatinine only (HR 1.52, 1.10–2.10, p = 0.011) and serum creatinine with urine output-based KDIGO criteria (HR 1.77, 1.18–2.67, p = 0.006). No significant differences between groups were observed for AKI recovery patterns or mortality. Conclusion Concomitant vancomycin and piperacillin/tazobactam administration in adult ICU patients was independently associated with an increased risk of AKI.

Background: Irish and European antimicrobial resistance (AMR) surveillance data have highlighted increasing AMR in Enterobacterales and vancomycin resistance in Enterococcus faecium (VRE). Antimicrobial consumption (AC) in Irish hospital settings is also increasing. Methods: A retrospective time series analysis (TSA) was conducted to evaluate the trends and possible relationship between AC of selected antimicrobials and AMR in Enterobacterales and vancomycin resistance in E. faecium, from January 2017 to December 2020. Results: Increased AC was seen with ceftriaxone (P = 0.0006), piperacillin/tazobactam (P = 0.03) and meropenem (P = 0.054), while ciprofloxacin and gentamicin use trended downwards. AMR rates in Escherichia coli, Klebsiella pneumoniae and other Enterobacterales were largely stable or decreasing, an increase in ertapenem resistance in the latter from 0.58% in 2017 to 5.19% in 2020 (P = 0.003) being the main concern. The proportion of E. faecium that was VRE did not changed significantly (64% in 2017; 53% in 2020, P = 0.1). TSA identified a correlation between piperacillin/tazobactam use and the decreasing rate of ceftriaxone resistance in E. coli. Conclusion: Our data suggest that the hospital antimicrobial stewardship programme is largely containing, but not reducing AMR in key nosocomial pathogens. An increase in AC following the COVID-19 pandemic appears as yet to have had no impact on AMR rates.

Objectives: To investigate the clinical distribution and drug resistance of Klebsiella pneumoniae pulmonary infection in patients with hypertensive intracerebral hemorrhage after minimally invasive surgery. Methods: A total of 658 patients with hypertensive intracerebral hemorrhage who underwent minimally invasive surgery admitted to the intensive care unit (ICU) and the Department of Neurology of Affiliated Hospital of Hebei University from January 2015 to January 2020 were enrolled and divided into two groups: the observation group and the control group. Three hundred and thirty-three cases with postoperative pulmonary infection were included into the observation group, and 325 cases without postoperative pulmonary infection were divided into the control group. The intubation time, neurological deficiency score and Glasgow coma scale (GCS) of the two groups were analyzed and compared. Automatic microbial identification system was utilized to isolate bacteria from patients in the observation group, identify Klebsiella pneumoniae, and analyze Klebsiella pneumoniae infection, clinical department distribution, and age distribution. The Kirby-Bauer method was adopted to carry out the drug susceptibility test of Klebsiella pneumoniae infection. Results: The intubation time and neurological deficiency score of patients with hypertensive cerebral hemorrhage in the observation group were significantly higher than those in the control group (p

Published data demonstrate that management of uncomplicated pediatric appendicitis with antibiotics-alone is safe and frequently successful. Randomized controlled trials (RCT) comparing antibiotics-alone to appendectomy are lacking, alongside insight into drivers of failure. We sought to validate the antibiotics-alone approach and identify barriers to success using an RCT design.Patients aged 6-17 years with uncomplicated appendicitis were randomized to appendectomy or intravenous piperacillin/tazobactam for 24-48 h followed by 10 days of oral ciprofloxacin/metronidazole. Enrollment required symptoms48 h, WBC18, appendiceal diameter11 mm, and radiographic absence of perforation. Lack of clinical improvement or persistently elevated WBC resulted in appendectomy. Primary outcomes were 1-year success rate of antibiotics-alone and quality-of-life measures.Among 39 children enrolled over 31 months, 20 were randomized to antibiotics-alone and 19 to surgery. At 1 year, 6 nonoperative patients underwent appendectomy (70% success). Four cases were not true antibiotic failures but instead reflected "pragmatic" challenges to executing nonoperative algorithms. Only 2 cases represented recurrent/refractory appendicitis, suggesting a 90% adjusted 1-year success rate. Parental PedsQL™ scores were similar between treatment cohorts (91.3 vs 90.2, P = 0.32). Children treated with antibiotics-alone had faster return to activity (2.0 vs 12 days, P = 0.001) and fewer parental missed work days (0.0 vs 2.5, P = 0.03).These data corroborate findings from non-randomized studies suggesting 70-90% of uncomplicated pediatric appendicitis can be treated with antibiotics-alone, with fewer disability days. Failures appear multifactorial, often reflecting practical hurdles and not antibiotic limitations. As surgeons consider nonoperative protocols for uncomplicated appendicitis, these data further inform the variability of treatment success.1; randomized controlled trial.

Background The rate of surgical site infection (SSI) after appendectomy for complicated appendicitis (CA) was high at our children's hospital. We hypothesized that practice standardization, including obtaining intra-operative cultures of abdominal fluid in patients with CA, would improve outcomes and reduce healthcare utilization after appendectomy. Methods A quality improvement team designed and implemented a clinical practice guideline for CA that included obtaining intra-operative culture of purulent fluid, administering piperacillin/tazobactam for at least 72 h post-operatively, and transitioning to oral antibiotics based on intraoperative culture data. We compared outcomes before and after guideline implementation. Results From July 2018-October 2019, 63 children underwent appendectomy for CA compared to 41 children from January-December 2020. Compliance with our process measures are as follows: Intra-operative culture was obtained in 98% of patients post-implementation; 95% received at least 72 h of piperacillin-tazobactam; and culture results were checked on all patients. Culture results altered the choice of discharge antibiotics in 12 (29%) of patients. All-cause morbidity (SSI, emergency department visit, readmission to hospital, percutaneous drain, unplanned return to operating room) decreased significantly from 35% to 15% (p=0.02). Surgical site infections became less frequent, occurring on average every 27 days pre-implementation and every 60 days after care pathway implementation (p=0.03). Conclusions Utilization of a clinical practice guideline was associated with reduced morbidity after appendectomy for CA. Intra-operative fluid culture during appendectomy for CA appears to facilitate the selection of appropriate post-operative antibiotics and, thus, minimize SSIs and overall morbidity.

The treatment of K. pneumoniae infections has become more difficult due to the emergence of multidrug-resistant strains. This study aimed to evaluate antimicrobial resistance patterns and detect different types of beta-lactamase genes among MDR and non-MDR Klebsiella pneumoniae in various clinical samples. A total of 150 Klebsiella pneumoniae were identified from different clinical samples by conventional microbiological procedures. Antibiotic sensitivity was detected by the Kirby-Bauer disc diffusion method. Extended-spectrum beta-lactamase, Metallo-β-lactamase, and carbapenemase were phenotypically detected by double-disk synergy test, combined disk assay, and modified Hodge test. PCR also detected different β lactamase genes and virulence genes. The majority of Klebsiella pneumoniae were multi-drug resistant (82%). The bacteria were found resistant to most β-lactam antibiotics, aminoglycosides, ciprofloxacin, cotrimoxazole, carbapenem, piperacillin, and tazobactam. However, only about 0.7% colistin resistance was observed. A double-disk synergy test was performed among the isolates for phenotypic detection of ESBL producing Klebsiella pneumoniae. Only 16.6% of isolates were found to be ESBL producers. Among β-lactamase genes, NDM (23.34%), OXA-48(8%), and KPC (7.3%) were detected. Other prevalent β lactamase genes VIM and IMP were not detected. In summary, the prevalence of MDR Klebsiella pneumoniae is high in Bangladesh, which may complicate the treatment of hospitalized patients.

Background: Antibiotics have been widely and efficaciously used for febrile neutropenia in pediatric patients. However, reports are scant regarding the risk factors for recurrent fever after discontinuation of antibiotics in a neutropenic state. Here, we investigated these factors using data from our previously reported randomized study regarding meropenem and piperacillin/tazobactam for pediatric patients with febrile neutropenia. Procedure: We analyzed a total of 170 febrile episodes where first line antibiotic treatment was effective and discontinued before neutrophil recovery. Results: Recurrent fever was observed in 31 episodes (18%). The median interval from antibiotics discontinuation to recurrent fever was 5 days (0–27 days). Risk factors for recurrent fever were: incomplete remission of original disease; and high white blood cell count, neutrophil count, and C reactive protein levels at start of antibiotics. Moreover, lower neutrophil count at discontinuation of antibiotics, duration of neutropenia, and onset day of febrile neutropenia from start of neutropenia were also risk factors of recurrent fever. In multivariate analysis, neutrophil count at discontinuation of antibiotics

Objectives: The prevalence of Gram-negative bacteria (GNB) demonstrating extensive, multiple antimicrobial resistance is increasing in England, leaving few treatment choices. Cefiderocol is a novel siderophore cephalosporin approved in Europe for the treatment of aerobic GNB infections in adults with limited treatment options. We report pooled data for a clinical isolate set collected in England between 2014–2018. Methods: MICs were determined by broth microdilution according to International Organization for Standardization guidelines. Cefiderocol susceptibility was tested using iron-depleted cation-adjusted Muller–Hinton broth. Susceptibility rates were based on EUCAST breakpoints. In the absence of a species-specific breakpoint, pharmacokinetic/pharmacodynamic breakpoints were used. Results: Of 1886 isolates from England [74.1% Enterobacterales (18.7% Escherichia coli, 17.2% Klebsiella pneumoniae), 25.9% non-fermenters (18.4% Pseudomonas aeruginosa, 3.7% Acinetobacter baumannii)], 98.7% were cefiderocol-susceptible. Cefiderocol susceptibility in Enterobacterales (99.0%) was significantly (P < 0.01) greater than ceftolozane/tazobactam (94.3%), but similar to meropenem (99.3%) and ceftazidime/avibactam (99.4%). Overall, cefiderocol susceptibility (98.0%) in non-fermenters was significantly (P < 0.01) higher than comparators (range, 84.5–92.4%). Susceptibility to cefiderocol was 98.3–99.6% by infection source and was significantly (P < 0.01) greater than comparators for isolates from patients with nosocomial pneumonia (cefiderocol, 98.3%; comparators range, 79.8–93.8%). Excluding intrinsically meropenem-resistant Stenotrophomonas maltophilia, 47/1846 isolates (2.5%) were meropenem-resistant. A high proportion of meropenem-resistant P. aeruginosa were susceptible to cefiderocol (95.0%). All S. maltophilia isolates (40/40) were cefiderocol-susceptible. Conclusion: A substantial proportion of clinical isolates from England, representing a wide range of pathogens across multiple infection sources, was cefiderocol-susceptible. Cefiderocol retained activity against meropenem-resistant strains.

In India, the most common complication of lower limb amputated stump is infection, and it accounts 53.5% of total amputation. The published studies on prevention and management of such infection are very few. All the patients presenting with infection of amputated lower limb stump between 2010 and 2015 were included in this descriptive study. Diagnosis was confirmed by clinical, hematological, radiological, and microbiological test, i.e., culture and sensitivity of wound. Based on sensitivity report, treatment was started. There were 62 patients with 80 amputated lower limb stump infections. The most common presentation was sinus tract (54.8%). The most common cultured pathogen was Pseudomonas aeruginosa (39%). The most sensitive antibiotic was Piperacillin + Tazobactam (82.25%), followed by imipenem (75%), and levofloxacin (58.75%). More than 60% of Indian population lives in rural area. The primary mode of healthcare services in India is peripheral health centers. The first choice of drug therapy in management of amputated lower limb stump infection can be levofloxacin. Mishra S, Kumar DK, Gupta AK, et al. Lower Limb Stump Infection Management among Rural North Indian Population. Indian J Phys Med Rehab 2019;30(3):66–68.

WHAT IS KNOWN AND OBJECTIVE Betalactam antibiotics are the most frequent cause of hypersensitivity reactions. Rapid drug desensitization (RDD) is a technique that induces temporary tolerance to a drug allowing a patient to receive the optimal agent. The increased use of RDD and the lack of standardization among available protocols in terms of formulation, starting dose, number of steps and dosing frequency make it essential to determine the safety and appropriate management of these protocols, especially regarding reconstitution, diluents, stability and drug administration in order to guarantee reproducibility. We reviewed betalactam desensitization protocols in a tertiary hospital, in accordance with currently published practices and evaluated its use on patients over a period of three years. METHODS (a) We performed a literature search in PubMed, MEDLINE and Google Scholar databases for case reports and/or systematic reviews describing desensitization protocols for betalactam antibiotics. Pharmacokinetic parameters and physicochemical stability were checked for each antibiotic. (b) We retrospectively reviewed inpatients undergoing our antibiotic desensitization protocols from February 2018 to January 2021. Data and outcomes of desensitization procedures were analysed. RESULTS We developed nine RDD protocols: meropenem, ceftriaxone, ceftazidime, ampicillin, ceftolozane/tazobactam, cloxacillin, piperacillin/tazobactam, amoxicillin/clavulanate and penicillin G sodium. Five antibiotics have RDD protocols for two different doses, adjusted to patients with impaired renal function. Detailed data (diluent, total dose, volume, concentrations, duration and stability) of the protocol of each antibiotic used are provided. 28 desensitizations were performed in 17 patients, three of them with confirmed allergies by skin test. 26 out of 28 (92.9%) of them were successfully completed, including those three with positive skin results. The pathogens most frequently involved were E. faecalis and P. aeruginosa; both frequently associated with bacterial resistance. Meropenem, ceftriaxone and ceftazidime were the antibiotics most desensitized. 25 out of 26 (96.1%) procedures were successful in resolving the infection. WHAT IS NEW AND CONCLUSIONS Detailed information about compounding, dilution and stability is crucial to ensure safe and successful desensitization processes, as well as good coordination between the Allergy and Pharmacy departments. The increase in bacterial resistance to many of the commercially available antibiotics limits the therapeutic options for treating multidrug-resistant infections; in those situations, antibiotic desensitization may be a key therapeutic option. Although there is a broad consensus in limiting the use of RDD to patients with confirmed allergy, in usual clinical practice its application in those strongly suspected of having type I hypersensitivity is still observed. Our betalactam desensitization protocols have shown themselves to be safe and effective, as evidenced by data from the 17 patients on whom they have been tested.

β-Lactams are the most commonly used antibiotics in intensive care units (ICUs). As critically ill patients often experience pharmacokinetic aberrations, and rates of antimicrobial resistance vary between hospital settings, reliance on tertiary sources or package labeling to guide empiric dosing often results in suboptimal β-lactam exposure. The primary objective was to identify β-lactam regimens capable of achieving ≥90% cumulative fraction of response (CFR) against 7 Gram-negative pathogens within 4 ICUs at our institution. Unit-specific minimal inhibitory concentration (MIC) distribution data was used in combination with published pharmacokinetic parameters in critically ill patients to perform Monte Carlo simulations. The percentage of time for which the unbound concentration of antibiotic remained above the MIC (%ƒT > MIC) was used as the pharmacodynamic target: 70%ƒT >MIC for cefepime, 40%ƒT > MIC for meropenem, and 50%ƒT > MIC for piperacillin/tazobactam. Regimens were modeled to determine the likelihood of achieving ≥90% CFR. Overall, intermittently dosed cefepime, meropenem, and piperacillin/tazobactam failed to achieve ≥90% CFR for every organism. Cefepime 2 g intermittent bolus every 8 hours failed to achieve ≥90% CFR for Klebsiella pneumoniae or Enterobacter cloacae despite susceptibility rates exceeding 90%. Piperacillin/tazobactam 4.5 g prolonged infusion (PI) every 6 hours achieved

Introduction Combined use of vancomycin (VCM) and piperacillin/tazobactam (PIPC/TAZ) has been reported to increase the incidence of acute kidney injury (AKI). However, the risk factors associated with AKI after VCM and PIPC/TAZ (VPT) administration have not yet been identified. Therefore, we retrospectively assessed patients treated with VPT to investigate the risk factors for AKI development. Methods The study involved patients who were treated with VPT from January 1, 2016 to March 31, 2020. The patients were divided into the AKI or non-AKI group. The clinical characteristics of patients and antimicrobial therapy were compared between the groups. Their association with AKI risk was evaluated using multivariate logistic regression analysis. Results In total, 182 patients were included, with 118 in the non-AKI group and 64 in the AKI group. Therefore, the incidence of AKI was 35.2 %. The initiation of VPT combination therapy on the same day and concomitant use of vasopressors were associated with an increased risk of AKI (odds ratio [OR] 2.55, 95 % confidential interval [CI] 1.20–5.44 and OR 3.22, 95 % CI 1.31–7.89, respectively). Conclusion Our findings suggest that the concomitant use of vasopressors and initiating VPT combination therapy on the same day are likely risk factors for AKI development.

Introduction Colistin is used to treat severe antibiotic-resistant Gram-negative infections (GNIs). With the rise of antibiotic resistance, colistin has been used increasingly as a ‘last-line’ therapy for multidrug-resistant GNIs. We evaluated the incidence of acute kidney injury (AKI) and mortality among patients receiving colistin or one of the new β-lactam/β-lactamase inhibitors (βL + βLI) (ceftazidime/avibactam, ceftolozane/tazobactam, or meropenem/vaborbactam). Methods This retrospective cohort study used data from the Premier Healthcare Database. The cohort included propensity score-matched adults with an inpatient stay between January 2016 and December 2018. Patients given both colistin and BL + BLI as treatment for ≥ 72 h were excluded. AKI was defined as acute renal failure or dialysis during hospitalization with antibiotic administration. Propensity score matching was used to control for selection bias and confounding. Logistic regression evaluated associations between treatment, AKI, and in-hospital mortality. Results The total number of patients in the matched cohorts were 256 in each. Overall, 23.8% and 13.3% of patients receiving colistin or new βL + βLI agents, respectively, experienced AKI during hospitalization (p = 0.002); odds of AKI for colistin were 3.0 (95% CI 1.71, 5.21). Following propensity score-matching, patients without baseline renal disease experienced AKI during hospitalization to a higher degree in the colistin group compared to the βL + βLI group (17.1% vs. 6.8%); colistin use was associated with 3.7 times higher odds (95% CI 1.84, 7.42) of AKI compared to βL + βLI agents. The odds of mortality in patients on colistin developing AKI were more than three times that of patients receiving a BL + BLI agent who developed AKI. Among patients receiving colistin, incident AKI was associated with 6.1 times higher odds (95% CI 2.53, 14.71) of mortality. Conclusions Patients receiving colistin for GNIs had significantly higher odds of AKI and mortality than those receiving βL + βLI. Supplementary Information The online version contains supplementary material available at 10.1007/s40121-021-00556-x.

Purpose Consensus is lacking regarding the optimal antibiotic treatment for pediatric complicated appendicitis. This study determined the optimal first-line antibiotic treatment for pediatric patients with complicated appendicitis based on peritoneal fluid cultures. Methods This retrospective study examined the cases of pediatric patients who underwent appendectomy for complicated appendicitis at our institution between 2013 and 2019. Peritoneal fluid specimens obtained during appendectomy were cultured for the presence of bacteria. Results Eighty-six pediatric patients were diagnosed with complicated appendicitis. Of them, bacteria were identified in 54 peritoneal fluid samples. The major identified bacteria were Escherichia coli (n=36 [66.7%]), Bacteroides fragilis (n=28 [51.9%]), α-Streptococcus (n=25 [46.3%]), Pseudomonas aeruginosa (n=10 [18.5%]), Enterococcus avium (n=9 [16.7%]), γ-Streptococcus (n=9 [16.7%]), and Klebsiella oxytoca (n=6 [11.1%]). An antibiotic susceptibility analysis showed E. coli was inhibited by sulbactam/ampicillin in 43.8% of cases versus cefmetazole in 100% of cases. Tazobactam/piperacillin and meropenem inhibited the growth of 96.9-100% of the major identified bacteria. E. coli (100% vs. 84.6%) and P. aeruginosa (100% vs. 80.0%) were more susceptible to amikacin than gentamicin. Conclusion Tazobactam/piperacillin or meropenem is a reasonable first-line antibiotic treatment for pediatric complicated appendicitis. In the case of aminoglycoside use, amikacin is recommended.

Streptococcus suis (S. suis) infection, a zoonotic infection with a global distribution, is clinically manifested by meningitis, followed by sepsis, infective endocarditis and arthritis. S. suis infection is not uncommon, but acute myocardial infarction (AMI), as an initial symptom, has not yet been reported. We report a case of S. suis infection with AMI as an initial symptom. The patient, a previously healthy butcher with no known risk factors for AMI, was admitted to hospital with a sudden onset of AMI. Then, thrombolytic therapy, anticoagulation therapy with nadroparin calcium and antiplatelet therapy with aspirin and ticagrelor were adopted. Two days later, blood cultures in aerobic and anaerobic bottles were positive for S. suis and he received antibiotic therapy with piperacillin/tazobactam. Then, his symptoms improved and he was transferred to a special infectious disease hospital for further treatment and was discharged upon complete recovery. To the best of our knowledge, this is the first reported case of AMI as the initial symptom of S. suis infection, which illustrates a possible new symptom of this important pathogen. For AMI patients with unexplained infections, and who are in close frequent contact with pigs and/or pork products, clinicians should be alert to the possibility of S. suis infections.

In the phase III RESTORE‐IMI 2 study (ClinicalTrials.gov: NCT02493764), the combination antibacterial agent imipenem/cilastatin/relebactam (IMI/REL) demonstrated noninferiority to piperacillin/tazobactam for the end points of all‐cause mortality at day 28 and favorable clinical response at the early follow‐up visit in adult participants with gram‐negative hospital‐acquired bacterial pneumonia/ventilator‐associated bacterial pneumonia (HABP/VABP). Existing population pharmacokinetic models for imipenem (IPM) and REL were updated using data from patients with HABP/VABP from RESTORE‐IMI 2. Creatinine clearance (CrCl), body weight, infection type, and ventilation status were significant covariates in the updated model. The following simulations were performed to calculate the pharmacokinetic/pharmacodynamic joint probability of target attainment among patients with HABP/VABP and varying degrees of renal function: augmented renal clearance (CrCl ≥150 ml/min), normal renal function (CrCl ≥90 to

Introduction Delayed methotrexate (MTX) clearance with the co-administration of piperacillin/tazobactam (PIPC/TAZ) has been reported. Penicillins have been associated with reduced MTX clearance but the evidence is limited. There are no cases described with cefepime but penicillins are listed as interacting with MTX. We aimed to reveal whether the co-administration of PIPC/TAZ or CFPM affects MTX clearance using data from an administrative database. Methods We used data from the JMDC database, a large insurance claims database constructed in Japan. We included patients who were prescribed PIPC/TAZ or CFPM between days 1 and 3 in high-dose MTX (HD-MTX). We compared one co-administration episode (with PIPC/TAZ or CFPM) to one control episode (without), as a match-control study of two different episodes in the same patient. The primary outcomes were the duration and cumulative dose of leucovorin (LV) as a surrogate indicator of delayed MTX clearance. Results Three patients who were co-administered PIPC/TAZ and 16 patients who were co-administered CFPM with HD-MTX were included. In the PIPC/TAZ group, the duration and the cumulative doses of LV were similar in co-administration and control episode (median 3.0 vs. 3.0 days and 288.0 vs. 219.0 mg). In the CFPM group, the duration and the cumulative doses of LV were not significantly different in co-administration and control episode (3.0 vs. 4.0 days and 169.5 vs. 258.0 mg). Conclusions Our findings revealed that PIPC/TAZ did not necessarily cause a delay in MTX clearance during HD-MTX therapy. Moreover, the co-administration of CFPM with HD-MTX did not affect MTX clearance.

Pseudomonas aeruginosa isolates were consecutively collected from patients with pneumonia in 29 medical centers in 2020 and susceptibility tested by broth microdilution method. Ceftazidime-avibactam (95.5% susceptible), imipenem-relebactam (94.3% susceptible), and ceftolozane-tazobactam (93.3% susceptible) were the most active compounds after colistin (99.5% susceptible). Susceptibility rates for the β-lactam/β-lactamase inhibitor combinations (BL/BLIs) varied against isolates resistant to piperacillin-tazobactam, meropenem, imipenem, and/or ceftazidime. Ceftazidime-avibactam was the most active BL/BLI against resistant subsets from Western Europe, whereas imipenem-relebactam was slightly more active than other BL/BLIs against resistant subsets from Eastern Europe. Susceptibility rates were markedly lower in Eastern Europe than Western Europe.

OBJECTIVES: The aim of this study was to determine the prevalent aerobic vaginal bacteria and their antibiogram to commonly prescribed antibiotics for the treatment of aerobic vaginitis (AV). METHODOLOGY: A total of 200 high vaginal swabs (HVS) samples were collected from different AV suspected patients visiting Khyber Teaching Hospital (KTH) and processed for identification of bacterial isolates followed by antibiotic susceptibility patterns as per CLSI protocols. RESULTS: Out of 200 clinical samples, 70 (35%) HVS isolates yielded bacterial growth. Of the isolates, E.coli was the common pathogen 36 (51.4%) followed by S.aureus 20 (28.5%), Enterobacter spp 08 (11.4%), Pseudomonas spp 04 (5.7%) and Citrobacter spp 02 (2.8%). The highest prevalence was observed in the age group of 21-35 years (31.4%) followed by age groups 16-20 years (25.7%) and 26-30 years. S.aureus isolates (n=20) were resistant to ciprofloxacin (90%), cephradine (70%), erythromycin (70%), gentamicin (50%) and cefotaxime (40%) while 1 (5%) of each isolate was resistant to methicillin and vancomycin. Majority of the gram-negative isolates (n=50) were resistant to cotrimoxazole, cephalosporins, quinolones, aminoglycosides and susceptible to carbapenems, tigecycline, sulbactam and tazobactam. CONCLUSION: Aerobic vaginitis should be treated very selectively in order not to kill the beneficial bacteria. Before treating AV, the causative agents should be accurately identified and tested for drug susceptibility patterns and empirical antibiotic therapy should be avoided.

Objetivo: Avaliar a importância do farmacêutico clí­nico tanto na utilização dos antimicrobianos, quanto na redução de custo desses medicamentos.Método: O estudo caracterizado como descritivo, com abordagem quantitativa foi realizado no perí­odo de outubro a dezembro de 2016 em uma Unidade de Terapia Intensiva de um hospital público na cidade de Caruaru-PE. A coleta de dado ocorreu por meio de análise documental utilizando como ferramenta o sistema operacional padrão MV200.Resultados: Verificou-se uma maior utilização de piperacilina+tazobactam e meropenem, ambos antibióticos com amplo espectro de ação, evidenciando a escolha de terapias por parte dos protocolos do hospital com essa caracterí­stica. Entretanto, não se observa uma redução de gastos significativos em decorrência de um alto consumo ainda prevalente de antimicrobianos por pacientes de UTI. Conclusão: Diante dos resultados, infere-se que a ação de um farmacêutico clí­nico na Unidade de Terapia Intensiva auxiliaria com um maior controle dessas prescrições, evitando interações medicamentosas e atendendo í s necessidades de cada paciente.

Background The randomized, double-blind, phase 3 ASPECT-NP trial evaluated the efficacy of 3 g of ceftolozane/tazobactam (C/T) versus 1 g of meropenem infused every 8 h for 8 to 14 days for treatment of adults with hospital-acquired bacterial pneumonia (HABP) or ventilator-associated bacterial pneumonia (VABP). We assessed the probability of target attainment and compared efficacy outcomes from ASPECT-NP in participants with augmented renal clearance (ARC) versus those with normal renal function. Methods Baseline renal function was categorized as normal renal function (creatinine clearance 80–130 mL/min) or ARC (creatinine clearance > 130 mL/min). Population pharmacokinetic models informed Monte Carlo simulations to assess probability of target attainment in plasma and pulmonary epithelial lining fluid. Outcomes included 28-day all-cause mortality and clinical cure and per-participant microbiologic cure rates at the test-of-cure visit. Results A > 99% and > 80% probability of target attainment was demonstrated for ceftolozane and tazobactam, respectively, in simulated plasma and epithelial lining fluid. Within treatment arms, 28-day all-cause mortality rates in participants with normal renal function (C/T, n = 131; meropenem, n = 123) and ARC (C/T, n = 96; meropenem, n = 113) were comparable (data comparisons presented as rate; treatment difference [95% CI]) (C/T: normal renal function, 17.6%; ARC, 17.7%; 0.2 [− 9.6 to 10.6]; meropenem: normal renal function, 20.3%; ARC, 17.7%; − 2.6 [− 12.6 to 7.5]). Clinical cure rates at test-of-cure were also comparable across renal function groups within treatment arms (C/T: normal renal function, 57.3%; ARC, 59.4%; − 2.1 [− 14.8 to 10.8]; meropenem: normal renal function, 59.3%; ARC, 57.5%; 1.8 [− 10.6 to 14.2]). Per-participant microbiologic cure rates at test-of-cure were consistent across renal function groups within treatment arms (C/T: normal renal function, 72.2% [n/N = 70/97]; ARC, 71.4% [n/N = 55/77]; 0.7 [− 12.4 to 14.2]; meropenem: normal renal function, 75.0% [n/N = 66/88]; ARC, 70.0% [n/N = 49/70]; 5.0 [− 8.7 to 19.0]). Conclusions C/T and meropenem resulted in 28-day all-cause mortality, clinical cure, and microbiologic cure rates that were comparable between participants with ARC or normal renal function. In conjunction with high probability of target attainment, these results confirm that C/T (3 g) every 8 h is appropriate in patients with HABP/VABP and ARC. Trial registration ClinicalTrials.gov identifier: NCT02070757, registered February 25, 2014; EudraCT: 2012-002862-11.

Purpose The combination of vancomycin and piperacillin/tazobactam (VAN + PTZ) provides a broad spectrum of activity against multiple pathogens. However, a major issue in previous research concerned significant nephrotoxicity associated with this drug combination, and most studies have been conducted in American and European countries, with no similar data available from China. Therefore, this study evaluated the nephrotoxic effects of VAN + PTZ in a large-scale Chinese cohort to determine the prevalence of acute kidney injury (AKI) in this population by comparing PTZ and vancomycin monotherapies and the combined use of vancomycin and β-lactam antibiotics. Methods This retrospective cohort study identified adult patients who received vancomycin either as monotherapy or in combination with PTZ or carbapenem (VAN + CAR) for at least 48 hours at Jiangsu Province Hospital from January 1, 2017, to December 31, 2018. Patients were also evaluated for the development of AKI, defined according to the Kidney Disease Improving Global Outcome criteria. Duration of vancomycin exposure, steady-state trough vancomycin concentrations, and other risk factors for AKI were assessed. A Bayesian network meta-analysis was conducted to validate our results and comparatively evaluate the nephrotoxicity of β-lactam antibiotics in combination with vancomycin. Findings In all, 752 patients were included in the present study. The prevalence of AKI was higher in the VAN + PTZ group than in the VAN and VAN + CAR groups (15.2% vs 4.0% and 6.0%, respectively). After adjustment for confounding factors, VAN + PTZ was still related to AKI (odds ratio [OR] = 4.37; 95% CI, 1.65–11.59; P = 0.003). The network meta-analysis indicated that VAN + PTZ was associated with a significantly higher risk for AKI than was VAN (OR = 3.23; 95% CI, 2.50–4.35), PTZ (OR = 2.86; 95% CI, 1.92–4.12), VAN + cefepime (FEP) (OR = 2.37; 95% CI, 1.80–3.19), or VAN + CAR (OR = 2.28; 95% CI, 1.64–3.21). However, there was no significant difference with respect to AKI prevalence among the VAN, PTZ, VAN + FEP, and VAN + CAR groups. Implications The prevalence of AKI was higher with VAN + PTZ therapy than with VAN or PTZ monotherapy or with the concurrent use of VAN and FEP or CAR in our study. Clinicians should adequately assess renal function and consider this differential risk for nephrotoxicity when choosing empiric antibiotics in hospitalized patients to minimize the rates of AKI.

Background Several viral, bacterial and fungal co-infections have been associated with increased morbidity and mortality among patients with COVID-19. We report a fatal case of severe COVID-19 pneumonia in a patient with a recent diagnosis of advanced HIV disease complicated by cryptococcal meningitis, disseminated tuberculosis and acute ischemic stroke. Case presentation A 37-year-old Ugandan woman was diagnosed with HIV infection 8 days prior to her referral to our center. She was antiretroviral naive. Her chief complaints were worsening cough, difficulty in breathing, fever and altered mental status for 3 days with a background of a 1-month history of coughing with associated drenching night sweats and weight loss. The reverse transcriptase-polymerase chain reaction for SARS-CoV-2 of her nasopharyngeal swab sample was positive. Chest radiograph demonstrated military pattern involvement of both lungs. The serum and cerebrospinal fluid cryptococcal antigen tests were positive. Urine lipoarabinomannan and sputum GeneXpert were positive for Mycobacterium tuberculosis. Computed tomography of the brain showed a large acute ischemic infarct in the territory of the right middle cerebral artery. Regardless of the initiation of treatment, that is, fluconazole 1200 mg once daily, enoxaparin 60 mg, intravenous (IV) dexamethasone 6 mg once daily, oral fluconazole 1200 mg once daily, IV piperacillin/tazobactam 4.5 g three times daily and oxygen therapy, the patient passed on within 36 hours of admission. Conclusion Co-infections worsen COVID-19 outcomes.

Escherichia coli ( E. coli) is the main cause of Gram-negative bacterial peritonitis among peritoneal dialysis patients. According to the 2016 update of the International Society for Peritoneal Dialysis Peritonitis Recommendations, drug susceptibilities of specific organisms should be regularly monitored. The aim of this study was to examine the evolution of antimicrobial resistance of E. coli peritonitis from 2006 to 2018. Two hundred and fifty-three episodes of E. coli peritonitis were enrolled in our study, corresponding to a rate of 0.024 episodes per patient-year. According to drug sensitivity test results, isolates were most sensitive to carbapenems, followed by cefmetazole, piperacillin/tazobactam, cefotetan and amikacin, with an overall rate of more than 90% in both cohorts. Cefazolin and ciprofloxacin resistance increased significantly from 2006–2011 to 2012–2018. Conversely, cefepime and ceftazidime resistance decreased significantly. The extended-spectrum β-lactamase (ESBL) rate fluctuated from 34.7% in 2006–2011 to 46.8% in 2012–2018. Compared with the ESBL-negative strains, ESBL-producing E. coli were more likely be resistant to ampicillin, ampicillin/sulbactam, cephalosporins, quinolones, aminoglycosides, furadantin and sulfamethoxazole and accounted for over 50% of the drug resistance. In the correlation analysis, E. coli displayed significantly increased resistance to cefazolin and ciprofloxacin, a finding correlated with ESBL production ( r = 0.883 and 0.276 respectively, p < 0.001 and p = 0.003). In conclusion, the rate of E. coli peritonitis declined stably in recent years, but the resistance to antimicrobial was high.

Introduction: Emerging resistance in microorganisms is a matter of great concern in health care setups. Bacterial isolate and AMR pattern changes from place to place and time to time. Unprofessional use of antibiotics has resulted in an increasing burden of antibiotic resistance. This study focused over the aerobic bacteriological profile and antibiotic resistance pattern in pus isolates. Materials and Methods: A retrospective study was carried out from June, 2020 to May 2021. 1174 pus samples collected during the study period were included. The samples were cultured on Blood and MacConkey agar. After aerobic incubation at 37°C for 18-24 hrs, organisms were identified by biochemical reactions, gram staining and antibiotic susceptibility was tested by Kirby Bauer disc diffusion method. Result: Among the total 1174 pus samples, 712 (60.6%) were male and 462 (39.3%) were females. 857(72.9%) samples showed positive results. Among them, Staphylococcus aureus was the most common isolate followed by Escherichia coli, Pseudomonas spp. and Klebsiella spp. The sensitivity of Staphylococcus aureus was highest with Vancomycin and Linezolid, whereas Enterobacterales and Pseudomonas were sensitive with Piperacillin tazobactam. Conclusion: Increasing resistance always poses a challenge in treating infections. The development of resistant strains of pathogens can be limited by the judicious use of antibiotics. This study shows the infecting bacterial isolates and their antibiogram from this area. Keywords: Pus, antimicrobial resistance, bacterial isolates.

Introduction: Blood stream infections continue to be the major cause of mortality and morbidity and hence early availability of direct susceptibility reports can be lifesaving. This study aims to ascertain if direct susceptibility testing (DST) can be used as a diagnostic tool in bacteremic patients and to correlate the results of both DST and standard antimicrobial susceptibility reports (AST), thereby serving to benefit both the patients and also to reduce the irrational use of antibiotics. Materials and Methods: An experimental study was carried out after obtaining waiver of consent, in a tertiary care centre. A total of 37 patients were included in the study after careful consideration of the inclusion and exclusion criteria. Gram staining report, bacteriological profile, direct susceptibility report, antimicrobial susceptibility report of all the isolates were documented. Statistical analysis was done by using IBM SPSS software. Results: Overall prevalence of sepsis was 40.5%. Gram negative bacteria were more commonly isolated (83.8) and Escherichia coli was the commonest isolate (51.4%). The antimicrobial resistance was observed maximum for amoxicillin/clavulanic acid (66.7%), ceftriaxone (60.6%), Cefotaxime (57.6%) and least for meropenem (9.1%), imipenem (6.1%). On comparison of DST with AST among 28 gram-negative Enterobacteriaceae isolates 15 minor errors (4.8%) and three major errors (0.97%) were recorded, with maximum errors being documented for piperacillin/tazobactam with five minor errors (17.9%) and one major error (3.6%). Conclusion: DST is an important tool for early institution of targeted therapy and should be considered as one of the step towards antibiotic stewardship intervention. Keywords: Blood stream infection, Blood culture, Direct susceptibility test, Disk diffusion

Pseudomonas aeruginosa remains a prominent nosocomial pathogen. Detection of carbapenemase-producing P. aeruginosa is vital to dictate antimicrobial therapy and infection control measures. A pragmatic, minimum inhibitory concentration-based algorithm using imipenem AND meropenem-resistant plus ceftazidime-, cefepime-, and piperacillin/tazobactam-nonsusceptible criterion was derived to guide carbapenemase testing in P. aeruginosa. This study was an assessment of the algorithm's test performance in a cohort of 985 nonduplicate P. aeruginosa isolates collected from 20 German medical laboratories. Susceptibility data were assessed in the algorithm using both Clinical and Laboratory Standards Institute (CLSI) and European Committee on Antimicrobial Susceptibility Testing (EUCAST) interpretations. Sensitivity and specificity were calculated to evaluate algorithm test performance. The original algorithm criteria resulted in high specificity (95-97%) using both CLSI and EUCAST criteria; however, it failed to capture five carbapenemase-harboring isolates testing piperacillin/tazobactam susceptibility (CLSI/EUCAST). Two carbapenemase-producing isolates were also meropenem susceptible per EUCAST. A modified algorithm utilizing imipenem OR meropenem-resistant plus ceftazidime and cefepime nonsusceptible, improved the sensitivity of the criteria without significantly compromising specificity (CLSI sensitivity/specificity: 96%/94% and EUCAST sensitivity/specificity: 96%/95%). Application of the modified algorithm criteria resulted in high sensitivity and specificity using both CLSI and EUCAST interpretations in a large cohort of clinical P. aeruginosa. Utilization of this algorithm can improve the efficiency of carbapenemase testing in the clinical laboratory.

Objectives To describe the real-world clinical use of ceftolozane/tazobactam (C/T) and associated outcomes in France. Patients and methods Multicenter, prospective cohort study conducted in 22 hospitals. All adult patients who received at least one dose of C/T were asked to participate (2018-2019). Patients were treated according to standard hospital practice and followed up until C/T stop. Results At the time of the analysis, 84 patients were evaluated. The median age was 64.8 years, and 67.9% (57/84) of patients were males. Fifty-seven patients (57/82, 69.5%) had one or more risk factors for multidrug-resistant (MDR) infections (missing MDR risk factor data for two patients). Most patients were critically ill and had several comorbidities. A majority (59/84, 70.2%) of patients had nosocomial infections. Half of all patients (n = 42) had a diagnosis of pneumonia, of which 69% (29/42) were hospital acquired. Overall, 90.5% (76/84) of patients had MDR bacteria. Pseudomonas aeruginosa was the most frequently isolated bacterium (71/80, 88.8%), including 93% (80/86) of C/T-susceptible strains. C/T was prescribed as the first-line treatment to 29.8% (25/84) of patients. A concomitant antibiotic treatment was prescribed to 48.8% (41/84) of patients, of whom 65.9% (27/41) were prescribed concomitant antibiotics at the same time as C/T initiation. Empirical C/T prescription was microbiologically appropriate in 11/16 patients after susceptibility testing. Most patients (44/72, 61.1%) were cured and four (4/72, 5.6%) deaths were reported. Conclusions The results showed that C/T was most frequently prescribed for documented cases of P. aeruginosa infections. Most outcomes were positive, including among pneumonia patients.

The World Health Organisation (WHO) has designated antibiotic resistance as one of the most challenging public health threats of the 21st century. Production of β-lactamase enzymes by Gram-negative bacteria is the main mechanism of resistance to β-lactam (BL), the most widely used antibiotic in clinics. In an attempt to neutralise the hydrolytic activity of these enzymes, β-lactamase inhibitors (BLIs) have been developed. First-generation BLIs include clavulanic acid, sulbactam and tazobactam. However, none of them cover all β-lactamase classes, and an increasingly wide panel of inhibitor-resistant bacterial strains has developed. Second-generation BLIs function via different mechanisms and were developed by novel scaffolds from which diazabicyclooctane (DBOs) and boronic acids have emerged. In this paper, we provide descriptions of promisor second-generation β-lactamase inhibitors, such as avibactam, vaborbactam and boronic acids, as well as several BL–BLI combinations that have been designed. While some combinations are now being used in clinical practice, most are presently limited to clinical trials or pre-clinical studies. In this paper, we emphasise the continuous need to develop novel and different BLIs to keep up with the multidrug-resistant bacteria that arise. At this time, however, second-generation BLIs constitute a promising and effective approach.

Antimicrobial resistance (AMR) threatens millions of people around the world and has been declared a global risk by the World Economic Forum. One of the important AMR mechanisms in Enterobacteriaceae is the production of extended-spectrum β-lactamases. The most common ESBL, CTX-M β-lactamases, is spread to the world by CTX-M-15 and CTX-M-14. Sulbactam, clavulanic acid, and tazobactam are first-generation β-lactamase inhibitors and avibactam is a new non-β-lactam β-lactamase inhibitor. We studied that avibactam, sulbactam, clavulanic acid, tazobactam, and quercetin natural flavonoids were docked to target protein CTXM-15. Subsequently, the complexes were simulated using the molecular dynamics simulations method during 100 ns for determining the final binding positions of ligands. Clavulanic acid left CTX-M-15 and other ligands remained in the binding site after the simulation. The estimated binding energies were calculated during 100 ns simulation by the MMGBSA-MMPBSA method. The estimated free binding energies of avibactam, sulbactam, quercetin, tazobactam, and clavulanic acid were sorted as –33.61 kcal/mol, –16.04 kcal/mol, –14 kcal/mol, –12.68 kcal/mol, and –2.95 kcal/mol. As a result of both final binding positions and free binding energy calculations, Quercetin may be evaluated an alternative candidate and a more potent β-lactamases inhibitor for new antimicrobial combinations to CTX-M-15. The results obtained in silico studies are predicted to be a preliminary study for in vitro studies for quercetin and similar bioactive natural compounds. These studies are notable for the discovery of natural compounds that can be used in the treatment of infections caused by β-lactamase-producing pathogens.

Purpose Guidelines from the National Institutes of Health support the use of balanced crystalloid solutions such as Normosol-R (Hospira, Lake Forest, IL) for patients with coronavirus disease 2019 (COVID-19). However, their clinical utility is hindered by a lack of Y-site compatibility data that is essential for use in patients with limited intravenous access. The objective of this study was to determine the physical compatibility of selected intensive care unit medications with Normosol-R. Methods The study involved laboratory simulation of Y-site compatibility. Medications tested included amiodarone, caspofungin, dexmedetomidine, dobutamine, dopamine, epinephrine, levofloxacin, norepinephrine, pantoprazole, phenylephrine, piperacillin/tazobactam, vancomycin, and vasopressin. Tests performed were visual assessment with Tyndall light, turbidity measurement, and pH assessment. Tests were performed immediately after mixing (with the exception of turbidity testing) and after 1 hour and 4 hours. Results Incompatibility was defined as observation of haze, gas, particulate, or color change or admixture turbidity above 0.3 or above 0.5 nephelometric turbidity unit (NTU), depending on whether the baseline turbidity was less than or greater than 0.5 NTU, respectively. Analysis of solubility and compatibility based on change from baseline to admixture pH in relation to the reported −log of the acid dissociation constant (pKa) was performed. There was no evidence of visual incompatibility for any of the admixtures when mixed with Normosol-R. Turbidity exceeded the defined threshold with pantoprazole, phenylephrine, and highly concentrated norepinephrine. Pantoprazole was the only test medication with a significant pH change when compared to its pKa. Conclusion Normosol-R is compatible for Y-site administration with all tested medications except for pantoprazole, phenylephrine, and highly concentrated norepinephrine, allowing for potential increased use in patients with COVID-19.

Background Respiratory infections are one of the most common causes of morbidity and mortality. This study examined antimicrobial susceptibility of common respiratory isolates from veterans. Methods Sputum culture data from the Veteran Health Administration were obtained retrospectively between January 2009 and 2019. Cumulative antibiograms were constructed for bacterial isolate susceptibility. Results Sputum and bronchial cultures from approximately 10,345 veterans were included each year. Haemophilus influenzae has maintained high levels of susceptibility to third generation cephalosporins from 2009 (99.7%) to 2018 (97.2%). Third generation cephalosporin susceptibilities amongst Klebsiella pneumoniae have trended upward from 2009 to 2018 as well (79.1% vs 86.4%). In Pseudomonas aeruginosa isolates, there has been an increase in susceptibility rates to cefepime from 2009 to 2018 (79.6%, to 86.6%), gentamicin (81.5% to 89.1%), and piperacillin/tazobactam (86.5% to 90%). Fluoroquinolone susceptibilities amongst Escherichia coli have remained low but stable between 2009 and 2018. Third generation cephalosporin susceptibilities for S. pneumoniae improved slightly from 92.2% to 95% between 2009 and 2018 while susceptibility to azithromycin trended down slightly from 56.8% in 2009 to 51.7% in 2018 for S. pneumoniae. Discussion The antibiogram of sputum isolates from the VA Healthcare System were examined to determine changes in patterns of resistance over a decade of use. Conclusions This large-scale study investigated nationwide sputum culture susceptibility trends. Avoidance of macrolides for empiric treatment of community acquired pneumonia and avoidance of fluoroquinolones for empiric treatment of hospital acquired or ventilator associated pneumonia may be warranted based on susceptibility trends.

Background Therapeutic failure is a frequent issue in the management of post-operative peritonitis. Objectives A post hoc analysis of the prospective, multicentre DURAPOP trial analysed the risk factors for failures in post-operative peritonitis following adequate source control and empirical antibiotic therapy in critically ill patients. Patients and methods Overall failures assessed post-operatively between Day 8 and Day 45 were defined as a composite of death and/or surgical and/or microbiological failures. Risk factors for failures were assessed using logistic regression analyses. Results Among the 236 analysed patients, overall failures were reported in 141 (59.7%) patients, including 30 (12.7%) deaths, 81 (34.3%) surgical and 95 (40.2%) microbiological failures. In the multivariate analysis, the risk factors associated with overall failures were documented piperacillin/tazobactam therapy [adjusted OR (aOR) 2.10; 95% CI 1.17–3.75] and renal replacement therapy on the day of reoperation (aOR 2.96; 95% CI 1.05–8.34). The risk factors for death were age (aOR 1.08 per year; 95% CI 1.03–1.12), renal replacement therapy on reoperation (aOR 3.95; 95% CI 1.36–11.49) and diabetes (OR 6.95; 95% CI 1.34–36.03). The risk factors associated with surgical failure were documented piperacillin/tazobactam therapy (aOR 1.99; 95% CI 1.13–3.51), peritoneal cultures containing Klebsiella spp. (aOR 2.45; 95% CI 1.02–5.88) and pancreatic source of infection (aOR 2.91; 95% CI 1.21–7.01). No specific risk factors were identified for microbiological failure. Conclusions Our data suggest a predominant role of comorbidities, the severity of post-operative peritonitis and possibly of documented piperacillin/tazobactam treatment on the occurrence of therapeutic failures, regardless of their type.

Rational pharmacotherapy of COVID-19 in the world, treatment protocols, prescriptions of antibacterial (AB), antiviral (AV) medicines have been systematically improved due to updated data of evidence-based medicine. The study aim was to analyze the trends of AB, AV consumption for outpatients with confirmed COVID-19: to study the reasons of the growing demand for AB, AV; optimization of pharmaceutical care directions for rational cost-effectiveness use, prevention antibiotic resistance. Methods – the survey on consumption trends of AB and AV, side effects of AB; survey data of 205 pharmacists, 5 regions of Ukraine; pharmacoeconomic analysis «cost-minimization», content analysis of instructions, side effects. Analysis of surveys showed that the demand on AB, AV increased by 50.1% to 2019, such groups: beta-lactams, respiratory fluoroquinolones, macrolides. We found the most often were released: azithromycin, cefoperazone, cefipime, piperacillin with tazobactam, meropenem. Pharmacists noted that patients often used AB, AV without a prescriptions, it complicates the release from pharmacies. So it is necessary to implement e-prescriptions for AB, AV for monitoring of effectiveness, side effects, to prevent antibiotic resistance in pandemic. We found 53.7% of pharmacists noted about insufficient of trade names, stocks of AB and AV. It is the difficulties to provide outpatients with covid-19. Content-analysis data showed the most common side effects during AB course. We identified the main directions of information pharmacist providing to prevent side effects, antibiotic resistance. We conducted the demand for AV, AV medicines increased by 50.1% vs to 2019. It was identified the AB groups, trade names in high demand. Used pharmacoeconomic analysis «cost-minimization», we established that depending on the manufacturer, an antibiotic course costs differ by 15.1 times. The necessity of including in the list of the reimbursement program «Affordable Medicines» the essential AB, AV, to reduce costs for COVID-19 outpatients was substantiated. We showed 83,1% of pharmacists consider the need of approval, implementation of «Protocol for symptomatic treatment of uncomplicated forms of COVID-19». It will improve the results of pharmaceutical care for COVID-19 patients due to GPP requirements.

Background Necrotizing enterocolitis (NEC) is one of the most serious complications in preterm infants. Probiotics have been used to prevent NEC. Safety is a major concern for this practice. Methods We reported a female preterm infant who received oral Lactobacillus rhamnosus GG but developed sepsis 12 days after the treatment. Cultures of blood and the catheter tip yielded L. rhamnosus. Next-generation sequencing was performed to analyze isolates from blood, stool, catheter, and product capsules. We also determined the capacities of these isolates to form biofilms. A literature review was performed. Results The patient was treated with ampicillin and piperacillin/tazobactam, and she subsequently recovered without complications. The analysis of genome sequences indicated that all the isolates belonged to the clone of L. rhamnosus GG (ATCC 53103), suggesting that sepsis was a catheter-related infection caused by the oral probiotic. L. rhamnosus GG (ATCC 53103) and the probiotic strain tested formed biofilms under all growth conditions. Isolates from the blood and catheter tip also formed biofilms, but the stool isolate did not. The capacity of intrinsic biofilm formation in L. rhamnosus GG depended on environmental factors and the type of culture medium. Literature review of L. rhamnosus GG sepsis in preterm and young infants found that nearly 60% of the patients had a suspected or confirmed infected catheter. Conclusion The study showed that the capacity of L. rhamnosus GG to form biofilms, especially in the presence of glucose, is a critical factor leading to the probiotic-related sepsis in preterm infants.

Objective: This study was carried out to evaluate the efficacy and prescribing pattern of antibiotics in the skin and skin structure infections (SSTIs) at tertiary care teaching hospital. Methods: In this prospective observational study, an attempt was made to evaluate the efficacy and prescribing pattern of antibiotics. Subjects were selected according to the inclusion and exclusion criteria and patient case sheets were analyzed for patient demographic details, results of physical examination and laboratory parameters, and prescription pattern. Results: Cellulitis was the most common skin and skin structure infection among the subjects, followed by an ulcer. Few patients showed discomforts such as pain, swelling, and purulent discharge. Surgical procedure has been done in 76 patients. Out of 99 patients, 11 patients showed a prolonged length of stay (LOS) (≥16 d), which is an indication of the poor efficacy of antibiotics. Intravenous to oral antibiotic therapy switch was seen in 47 patients, which indicates that the patient’s condition was improved. The mean length of hospital stay was 8.79 d. The majority of patients have been discharged within 15 d. Cephalosporins were the most frequently prescribed class of antibiotics in patients with skin and soft tissue infections. Metronidazole was the most frequently used antibiotic as monotherapy followed by cefuroxime. Piperacillin+Tazobactam was the most frequently used combination antibiotic. This study finds that the antibiotic treatment was efficacious in the majority of the patients. Conclusion: This study finds that the antibiotic treatment was efficacious in the majority of the patients.

Purpose A case of osteomyelitis caused by multidrug-resistant (MDR) Pseudomonas aeruginosa is reported. Summary An 84-year-old Caucasian male with an underlying history of type 2 diabetes, peripheral vascular disease, and coronary artery disease had chronic nonhealing wounds on his right foot. Wound care and a course of intravenous (IV) ertapenem with oral ciprofloxacin were ineffective. His initial wound culture grew Staphylococcus aureus, group G streptococcus and P. aeruginosa; the Pseudomonas was susceptible to multiple agents. The patient eventually required midtarsal amputation and angioplasties to his right leg. Twenty days after the operation, 2 openings were discovered at the surgical site, 1 of which was probed to the bone. He was readmitted 5 weeks after the operation. A repeat wound swab grew MDR P. aeruginosa and Finegoldia magna. The Pseudomonas was susceptible to gentamicin and colistin. The patient had revision of the infected amputation site with the goal of salvaging his right lower limb. The patient developed acute renal failure after 26 days of IV gentamicin, IV ceftriaxone, and oral metronidazole. Additional susceptibility testing was performed to identify alternatives. The bacteria were considered susceptible to IV fosfomycin, the last resort, by our microbiology laboratory. This was combined with ceftolozane/tazobactam followed by meropenem to treat the residual infection. After 2 weeks of IV fosfomycin, the patient’s wound improved and further amputation was avoided. Conclusion Our case demonstrates that IV fosfomycin may provide an effective salvage therapy when combined with β-lactams for the treatment of severe diabetic foot infection or osteomyelitis caused by MDR P. aeruginosa.

This article aimed to assess the safety and effectiveness of biodegradable stents in the management of benign biliary strictures. This is a retrospective observational study that included all adult patients who had biodegradable stent placement for a benign cause of biliary stricture between July 2016 and August 2019. Nineteen patients were included. Seventeen patients had liver transplant. One patient had hepaticojejunostomy due to primary sclerosing cholangitis and one patient had iatrogenic left main bile duct occlusion. Stents were successfully deployed in all 19 patients (technical success: 100%). Patency rate was 90% (17/19) at 6 months and 80% (12/15) at 12 months. Seven patients in the study had stricture recurrence and needed reintervention with mean time to reintervention of 418 days (range: 8–1,155 days). There was one major complication due to cholangitis and sepsis, which required a treatment course with piperacillin/tazobactam for 10 days. No procedure-related pancreatitis or deaths occurred. Biodegradable stents are a safe and effective treatment option for benign biliary strictures and can achieve long-term patency without the need for reinterventions.

Objective: Through historical comparison with our previous study published 10 years ago, this paper aims to provide latest analysis of local bacteriology of acute complicated appendicitis and evaluate the effects of early escalation of potent antibiotics on course of postoperative recovery. Methods: A 5-year retrospective review of all children receiving emergency laparoscopic appendicectomies for acute appendicitis from December 2014 to November 2019 was conducted. Results: 257 cases of acute appendicitis were included, 126 were complicated appendicitis (38 gangrenous, 88 ruptured). 96 had positive peritoneal swab culture, 53 (42.1%) grew resistant bacterial strains, including extended spectrum beta-lactamase producing E. coli (ESBL E. coli), Pseudomonas aeruginosa, against traditional empirical triple antibiotics. The prevalence had significantly increased over the past decade (p = 0.008). In our patients, piperacillin/tazobactam, ertapenem, gentamicin provided coverage of 69.8%, 45.3% and 45.3% respectively. For patients with early escalation of postoperative antibiotics, no statistical significance was identified in terms of postoperative complications (p = 0.883), or duration of antibiotics (p = 0.0615). Conclusion: Growing prevalence of resistant strains were observed over the decade. Piperacillin/tazobactam provided the best coverage (69.8%) against resistant bacterial strains in our patients. Early escalation of antibiotics failed to reduce postoperative complications and antibiotics duration. Type of Study: Clinical Research, Retrospective Historical Comparative Study Level of Evidence: Level III

Background: Infertility means the failure to achieve a clinical pregnancy after 12 months of regular unprotected sexual intercourse. It affects approximately 15% of couples. The male factor is the main cause of infertility in 20% of cases and contributes in about 50%. There are many etiologies for male factor infertility. Infectious processes contribute to about 15% of such cases. Citric acid has antioxidant and anti-inflammatory functions in tissues damaged by environmental factors. In addition, it favors the synthesis of glycosaminoglycans in various tissues. Citric acid levels are regulated by testosterone, and like fructose can be elevated in oligozoospermic and azoospermic subjects without a convincing clinical explanation. Objective: To evaluate effect of genital tract infection on level of citric acid in semen of infertile men. Patients and methods: This study was carried out on 30 infertile male patients. Patients were recruited from the Outpatient Clinic of Andrology Unit in Dermatology & Andrology and STDs Departments, Mansoura University Hospital for one year. Results: The mean age of the studied group was 29.57 ± 4.22 years. All studied samples were subjected to antimicrobial sensitivity tests. The most sensitive antibiotics were rifampicin, cefoprazone/sulbactam, amoxicillin/clavulanic acid and piperacillin/tazobactam. While the most resistant antibiotics were ciprofloxacin, cephalexin and levofloxacin. The mean of citric acid was significantly increased after receiving antibiotic (16.64 ± 2.24 versus 3.32 ± 1.40 mg/ejaculate before treatment). Conclusion: Citric acid was significantly increased after receiving antibiotic versus before male genital infection treatment.

Introduction Gram-negative nosocomial pneumonia (NP), including hospital-acquired bacterial pneumonia (HABP), ventilated HABP (vHABP), and ventilator-associated bacterial pneumonia (VABP), is a significant cause of morbidity and mortality. Common pathogens, including Enterobacterales and Pseudomonas aeruginosa, are prevalent in healthcare settings and have few effective treatment options due to high rates of antibacterial resistance. Resistant pathogens are associated with significantly worse outcomes, relative to patients with susceptible infections. Ceftolozane/tazobactam (C/T) has established efficacy in clinical trials of patients with NP. This review aims to collate data on C/T use for HABP/vHABP/VABP infections in real-world clinical practice. Methods This systematic literature review searched online biomedical databases for real-world studies of C/T used to treat Gram-negative respiratory tract infections (RTIs) between January 2009 and June 2020. Results Thirty-three studies comprising 658 patients were identified. Pneumonia was the most common infection treated with C/T (85%), with a smaller number of unspecified RTIs (9%) and tracheobronchitis (5%) reported. The majority of patients had respiratory infections caused by P. aeruginosa (92.8%), of which 88.1% were multidrug-resistant. Examination of these studies demonstrated an increase in the percentage of patients receiving the recommended dose of C/T for respiratory infections (3 g q8h or renal impairment-adjusted) over time (36.8% of patients in 2017 to 71.5% in 2020). Clinical success rates ranged from 51.4 to 100%, with 10 studies (55.6% of studies reporting clinical success) reporting clinical success rates of > 70%; microbiological success rates ranged from 57.0 to 100.0%, with three studies (60.0% of studies reporting microbiological success) reporting microbiological success rates of > 70%. Thirty-day mortality ranged from 0.0 to 33.0%, with nine studies (90% of studies reporting mortality) reporting 30-day mortality of

Background Community-acquired pneumonia (CAP) is a significant cause of morbidity and mortality, especially for the elderly and people who suffer from chronic conditions. This study was conducted to assess the clinical and microbiological characteristics and disease outcomes associated with the occurrence of CAP. Methods This retrospective chart review was conducted at King Abdulaziz Medical City, Jeddah, Saudi Arabia. Cases with documented clinical diagnosis of CAP during the period from 2016 to 2019 were included. Data were collected on demographic, clinical, and microbiological characteristics, used antimicrobials and patients’ outcomes, including length of hospital stay, intensive care unit admission, and mortality. Multivariate regression analysis was performed to identify risk factors for increased length of hospital stay. Results A total of two hundred and eighteen CAP episodes were identified. Patients had a median age of 64.5 years, and 54.1% were males. Microbiological diagnosis was established in 33 patients (15.1%). Admission to ICU and diagnosis of a neurological disease were significantly associated with longer hospital stay (>7 days). An average of 2.7 antimicrobials were used per patient, and the most common antibiotics used were Piperacillin/Tazobactam (46.3%), Doxycycline (44%), then Ceftriaxone (42.7%). Four patients (1.8%) died during hospital stay. Conclusions This retrospective analysis of CAP cases identified a lack of microbiological diagnosis and increased burden associated with disease severity and the need for hospitalization. The ability to identify CAP at an earlier stage will be a cornerstone to mitigate its impact on the healthcare system and ICU units.

Introduction Multidrug-resistant (MDR) Gram-negative infections complicate care of combat casualties. We describe the clinical characteristics, resistance patterns, and outcomes of Pseudomonas aeruginosa infections in combat casualties. Methods Combat casualties included in the Trauma Infectious Disease Outcomes Study with infections with and without P. aeruginosa isolation during initial hospitalization were compared. Pseudomonas aeruginosa from initial wound, blood, and serial isolates (≥7 days from previous isolate) collected from June 2009 through February 2014 was subjected to antimicrobial susceptibility testing, pulsed-field gel electrophoresis, and whole genome sequencing for assessing clonality. Multidrug resistance was determined using the CDC National Healthcare Safety Network definition. Results Of 829 combat casualties with infections diagnosed during initial hospitalization, 143 (17%) had P. aeruginosa isolated. Those with P. aeruginosa were more severely injured (median Injury Severity Score 33 [interquartile range (IQR) 27-45] vs 30 [IQR 18.5-42]; P Conclusions Pseudomonas aeruginosa continues to be a major cause of morbidity, affecting severely injured combat casualties, with emergent antimicrobial resistance upon serial isolation. Among MDR P. aeruginosa, active antimicrobials remain the oldest and most toxic. Despite ongoing efforts, outbreaks are still noted, reinforcing the crucial role of antimicrobial stewardship and infection control.

Objectives: To be effective, piperacillin/tazobactam (PTZ) unbound plasma levels need to be above the minimum inhibitory concentration (MIC) at least 50% of the time between dosing intervals (50% fT>MIC). This study aimed to compare the plasma piperacillin concentrations at the mid-dosing intervals (Cmid, 50% fT) and the proportion of patients achieving 50% fT>MIC between extended infusion (EI) and intermittent bolus (IB) methods in children. Methods: A prospective, randomised trial of EI versus IB of PTZ was conducted in children aged 1 month to 18 years. The PTZ dose was 100 mg/kg intravenously every 8 h. Patients were randomly assigned to receive EI (4-h infusion) or IB (30-min infusion). The primary outcome that was measured was plasma piperacillin Cmid. Results: Ninety patients with a median age (IQR) of 48 months (16–127) were enrolled. The most common indication for PTZ use was pneumonia (32.2%). Geometric mean (95% CI) plasma piperacillin Cmid of EI versus IB was 51.9 mg/L (40.6–66.6) versus 6.0 mg/L (4.2–8.6) (P < 0.01). The EI group had a trend of higher proportion of patients who achieved 50% fT>4xMIC (72.7% versus 30.0%; P = 0.06). Conclusions: PTZ administration with EI resulted in a higher Cmid compared with IB. In settings with increased piperacillin MICs, this approach should be implemented, particularly during the empirical treatment period.

Antimicrobial resistance patterns among different Escherichia coli isolates in the Kingdom of Saudi Arabia. This study aimed to investigate the patterns of antimicrobial resistance in E. coli isolated from different samples, and to identify potential pathogenic isolates in Riyadh, Kingdom of Saudi Arabia (KSA). In total, 51 bacterial isolates were recovered from 113 samples of human urine, food (raw meat, raw chicken, raw egg surface, and fresh vegetables), water, and air. Twenty-four E. coli isolates were tested for susceptibility to 26 antibiotics. The air sample isolates were most resistant to amoxicillin, ampicillin, amoxicillin/clavulanic acid, amoxicillin/sulbactam, piperacillin/tazobactam, cefalotin, cefuroxime, cefoxitin, cefixime, nitrofurantoin, and trimethoprim/sulfamethoxazol. The isolates from vegetable samples were resistant to amoxicillin, ampicillin, amoxicillin/clavulanic acid, amoxicillin/sulbactam, cefalotin, cefuroxime, cefoxitin, and cefixime. By contrast, the isolates from the water samples were resistant only to amoxicillin and ampicillin. The isolates from the human urine samples were most frequently resistant to norfloxacin (80%) followed by amoxicillin and ampicillin (70%), trimethoprim/sulfamethoxazole (55%), ciprofloxacin and ofloxacin (50%), cefalotin (30%), cefuroxime, cefixime and cefotaxime (25%), ceftazidime, ceftriaxone, cefepime and aztreonam (20%), amoxicillin/clavulanic acid, piperacillin/tazobactam and gentamicin (10%), and amoxicillin/sulbactam and cefoxitin (5%). Almost all (23/25, 95.8%) (n = 23) of the isolates were multi-drug resistant (MDR) (i.e., resistant to 3 or more classes of antibiotics), and 16.7% (n = 4) of those were positive for extended spectrum β-lactamase (ESBL). Of the 4 ESBL-producers, 3 were positive for blaCTX-M-15 and blaCTX-M1group, 2 were positive for blaCMY-2, and 1 each was positive for blaCTX-M-2 group, blaSHV, and blaOXA-47. The quinolone resistance gene qnrS was detected in 25% (n = 6) of the E. coli strains isolated from urine (N = 5) and air (N = 1) samples. The considerable number of antimicrobial resistance genes detected among E. coli isolates tested here is alarming and should raise public health concern.

The aim of this study was to screen fish farm water and fishes reared in fish farms within Abakaliki metropolis for multi-drug resistant Escherichia coli. Exactly 30 fish samples and 30 water samples were obtained from 10 different fish farms using sterile bottles from January to June, 2018. Samples were analyzed by standard microbiology methods. Susceptibility test to antibiotics was done by Kirby-Bauer disc diffusion technique. Double-disc synergy test was used to screen isolates for Extended Spectrum Beta-Lactamase (ESBL)-production. Exactly 54 (60%) E. coli and 12 (40%) E. coli were recovered from 90 different fish parts and 30 farm water samples, respectively. Isolates exhibited resistance (54% - 100%) to ceftazidime, aztreonam, cefotetan, cefuroxime, cefoxitin, piperacillin/tazobactam, ofloxacin, and ceftriaxone, but were susceptible to imipenem (80%), cefotaxime (60%), and gentamicin (57%). All the E. coli isolates form water and fish samples were negative for ESBL production. An average multiple antibiotic resistance index (MARI) value of 0.71 was recorded for the isolates. High prevalence of E. coli with multidrug-resistant traits in fish and water samples in our study area is a serious public health concern as this will make the treatment of infections, especially E. coli-associated foodborne diseases very difficult, thus leading to increase in health care cost, morbidity, and mortality. Key words: Escherichia coli, fish farm, multidrug-resistance, farm water, fish.

Purpose Small community hospitals often lack the human, financial, and technological resources necessary to implement and maintain successful antimicrobial stewardship programs now required by national regulatory and accrediting bodies. Creative solutions are needed to address this problem. Summary A 3-stage, quasi-experimental study including patients receiving antibiotics for pneumonia, skin and soft tissue infections, and urinary tract infections at a community hospital in Wisconsin from June 2013 to December 2015 was conducted. Remote telehealth prospective audit and feedback, guideline and order set management, and staff education targeting pharmacists, nurses, and physicians were provided during the 7-month intervention phase; these services were then removed for the postintervention period. Antimicrobial utilization (days of therapy [DOT] per 1,000 patient-days), hospital length of stay, and readmission and 30-day mortality rates were assessed to determine the impact of telehealth services on these outcomes. During the preintervention (baseline), intervention, and postintervention periods, 1,037 patients received antibiotics for the targeted infectious disease conditions. Patient demographics and rates of infectious disease conditions were similar among the different periods. Telehealth antimicrobial stewardship reduced broad-spectrum antibiotic use, including use of imipenem (from 83 to 31 DOT, P < 0.001), levofloxacin (from 123 to 99 DOT, P < 0.001), and vancomycin (from 104 to 85 DOT, P < 0.001), compared to utilization during the baseline period; mean (SD) length of stay also decreased (from 4.6 [2.8] days to 4.2 [2.6] days, P = 0.02). After nonrenewal of telehealth stewardship, vancomycin and piperacillin/tazobactam usage returned to or exceeded baseline levels. Conclusion The partnership between an academic medical center and a small community hospital improved antimicrobial utilization and clinical outcomes. Successful telehealth antimicrobial stewardship models should be explored further as a means to provide optimal patient care.