Don't Get Wound Up: Revised Fluoroquinolone Breakpoints for Enterobacteriaceae and Pseudomonas aeruginosa
Journal of Clinical Microbiology
Tam T. Van, Emi Minejima, Chiao An Chiu, Susan M. Butler-Wu
2019
Fluoroquinolones remain some of the more commonly prescribed antimicrobial agents in the United States, despite the wide array of reported side effects that are associated with their use. In 2019, the Clinical and Laboratory Standards Institute revised the fluoroquinolone antimicrobial susceptibility testing breakpoints for both Enterobacteriaceae and Pseudomonas aeruginosa. This breakpoint revision was deemed necessary on the basis of pharmacokinetic and pharmacodynamic analyses suggesting that the previous breakpoints were too high, in addition to the inability of the previous breakpoints to detect low-level resistance to this antibiotic class. In this minireview, we review the published data in support of this revision, as well as the potential challenges that these breakpoint revisions are likely to pose for clinical laboratories.
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Defining the Breakpoint Duration of Staphylococcus aureus Bacteremia Predictive of Poor Outcomes
Clinical Infectious Diseases
Emi Minejima, Nikki Mai, Nancy Bui, Melissa Mert, Wendy J Mack, Rosemary C She, Paul Nieberg, Brad Spellberg, Annie Wong-Beringer
2019
Persistent Staphylococcus aureus bacteremia (SAB) is defined based on varying duration in literature. The primary objective was to determine the risk of poor outcomes in relation to bacteremia duration.
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Utility of qSOFA score in identifying patients at risk for poor outcome in Staphylococcus aureus bacteremia
BMC Infectious Diseases
Emi Minejima, Vanessa Delayo, Mimi Lou, Pamela Ny, Paul Nieberg, Rosemary C. She & Annie Wong-Beringer
2019
The prognostic capability of the quick Sequential Organ Failure Assessment (qSOFA) bedside scoring tool is uncertain in non-ICU patients with sepsis due to bacteremia given the low number of patients previously evaluated.
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Expected Practice as a Novel Antibiotic Stewardship Intervention
Open Forum Infectious Diseases
Kabir Yadav, Eriko Masuda, Emi Minejima, Brad Spellberg
2018
“Expected practice” is a recently described method to alter clinical behavior. We implemented an expected practice around short-course antibiotic therapy, which was associated with decreased antibiotic utilization for multiple bacterial infections. Thus, we describe this expected practice as a novel, simple, and inexpensive tool to enhance antibiotic stewardship.
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Prospective Trial on the Use of Trough Concentration versus Area under the Curve To Determine Therapeutic Vancomycin Dosing
American Society for Microbiology Journals
Michael N. Neely, Lauren Kato, Gilmer Youn, Lironn Kraler, David Bayard, Michael van Guilder, Alan Schumitzky, Walter Yamada, Brenda Jones, Emi Minejima
2018
We hypothesized that dosing vancomycin to achieve trough concentrations of >15 mg/liter overdoses many adults compared to area under the concentration-time curve (AUC)-guided dosing. We conducted a 3-year, prospective study of vancomycin dosing, plasma concentrations, and outcomes. In year 1, nonstudy clinicians targeted trough concentrations of 10 to 20 mg/liter (infection dependent) and controlled dosing. In years 2 and 3, the study team controlled vancomycin dosing with BestDose Bayesian software to achieve a daily, steady-state AUC/MIC ratio of ≥400, with a maximum AUC value of 800 mg · h/liter, regardless of trough concentration. For Bayesian estimation of AUCs, we used trough samples in years 1 and 2 and optimally timed samples in year 3. We enrolled 252 adults who were ≥18 years old with ≥1 available vancomycin concentration. Only 19% of all trough concentrations were therapeutic versus 70% of AUCs (P < 0.0001). After enrollment, median trough concentrations by year were 14.4, 9.7, and 10.9 mg/liter (P = 0.005), with 36%, 7%, and 6% over 15 mg/liter (P < 0.0001). Bayesian AUC-guided dosing in years 2 and 3 was associated with fewer additional blood samples per subject (3.6, 2.0, and 2.4; P = 0.003), shorter therapy durations (8.2, 5.4, and 4.7 days; P = 0.03), and reduced nephrotoxicity (8%, 0%, and 2%; P = 0.01). The median inpatient stay was 20 days among nephrotoxic patients versus 6 days (P = 0.002). There was no difference in efficacy by year, with 42% of patients having microbiologically proven infections. Compared to trough concentration targets, AUC-guided, Bayesian estimation-assisted vancomycin dosing was associated with decreased nephrotoxicity, reduced per-patient blood sampling, and shorter length of therapy, without compromising efficacy. These benefits have the potential for substantial cost savings. (This study has been registered at ClinicalTrials.gov under registration no. NCT01932034.)
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