Research from a pediatric emergency department (ED) setting showed a 12 percentage-point increase in 

 among children who tested negative for a virus on a rapid respiratory pathogen (RRP) test.

 by Suchitra Rao, MBBS, MSCS, Associate Professor of the University of Colorado School of Medicine, supported a paradoxical finding that antibiotic prescribing is more likely in instances when RRP tests are administered, regardless of their results.

Now, Rao and colleagues are looking for means to explore better use and presence of antimicrobial stewardship in pediatric emergent settings. One idea, Rao told 

 during IDWeek, is the implementation of more stewardship educational materials, and guidances based on the general decision-making strategies of different care teams.

Rao also expressed interest in observing the same comparison—antibiotic prescribing in children given or not given RRP tests—with the addition of stewardship teams, as well as in instances when even faster test results are available.

“The good news is some of these newer molecule panels have excellent sensitivity and specificity,” she said. “So if the collection method is done in a reasonable way, then you can really rely on and trust that test.”

Rao also touched on the need limit antibiotic prescribing in patient populations—particularly compared with more at-risk populations.

“I think that the general thought when you’re dealing with someone over 65 with a lot of different medical comorbidities is that the risk of missing a bacterial infection has a huge impact,” Rao said. “And there’s often a trigger to pull on antibiotics in that group, and rightly so.”

In pediatrics, she noted, risk factors are different, and clinicians often have more time to make prescribing decisions. It actually may be more prudent in such cases when symptoms are not severe and the clinical setting is not acute, to assume a viral cause in a child, and make prescribing decisions based on test results.

Watch the full interview with Rao in the video above.

Videos

ID Week

Why it may be more prudent for prescribing clinicians to assume viral, rather than bacterial, infection while awaiting test results in presenting pediatric cases.

Suchitra Rao, MBBS, MSCS: Antibiotic Prescribing in Children

data pooled from the CONSTANT and PROTECT

 phase 3 trials showed tri-antigenic hepatitis B virus (HBV) vaccine (TAV) was faster and more efficacious in establishing anti-HBV titers versus mono-antigenic HBV vaccine (MAV) across all its observed patient populations.

The data, presented by study author Joanne Langley, MD, Professor of Pediatrics at the Canadian Center for Vaccinology, Dalhousie University, provided greater promise for vaccination options against HBV—a very necessary venture given the field’s current inability to cure HBV index cases with therapy.

“We’re not close to (HBV) eradication,” Langley told 

. “Like hepatitis C, there’s a carrier state for hepatitis B, and we don’t have a therapy where we can eradicate that carrier disease.”

Unfortunately, in regions of the world where chronic carriage of HBV is very prevalent, testing resources and capability lack behind, Langley explained.

“There’s this pool of apparently well people who may not even know they have hepatitis B carriage, and they can transmit to others,” she said. “And we have no way to interrupt that spread other than infection prevention and control.”

That makes these new findings for a promising TAV option all the more important, as the CONSTANT and PROTECT data will be used to support applications for regulatory use in prevention HBV.

However, more research may be warranted. Langley expressed interest in observing TAV’s prophylactic benefit for unique patient populations: immunocompromised patients, those on dialysis, and those with liver disease. She also hoped to gain better understanding of the immune response durability and length.

Watch the full interview with Langley in the video above.

The presenting IDWeek author discusses the implication of promising phase 3 data for a new HBV vaccine.

Joanne Langley, MD: The Need for Hepatitis B Preventive Care

 showed an 85% associated reduction in non-ventilator 

 infections in a medical center through 12 months among patients given oral care from nurses and nursing assistants, versus those provided standard care.

As the most common hospital-acquired infection, NVHAP’s significant reduction among patients given the very rudimentary oral care inspired investigators at the University of Massachusetts Amherst to consider the benefit of oral care as a therapeutic, not comfort, measure. Led by associate professor Karen Giuliano, PhD, they are now pursuing a randomized, controlled trial.

In the second segment of an interview with 

 during IDWeek, Giuliano explained how there may be added benefits for reducing mortality or lengthier hospital stay among patients with viral infection, including coronavirus 2019 (COVID-19).

Recent data from Germany has indicated antiseptic mouthwash could reduce COVID-19 viral load in the mouths of patients—meaning lessened risk of hospital spread.

“In previous viral pandemics, a lot of times you get sick from the virus, but what makes you really sick is the secondary bacterial infections, which is really what we’re talking about with hospital-acquired bacterial pneumonia,” she said.

Giuliano also explained how oral therapeutic care would likely fall to nurses and nursing assistants—a pair of positions already burdened with work in hospital settings.

“There’s not a lot of downsides to keeping a person’s mouth clean,” she said. “What we compete against is nurses, nursing assistants, and frontline clinicians of every kind dealing with tons of competing demands every day—and certainly, that’s worse with COVID.”

Watch the full interview with Giuliano in the video above.

New data may evidence oral care as a therapeutic measure to reduce bacterial and viral spread.

Karen Giuliano, PhD: Oral Care to Reduce Hospital Infections

Investigators from Brigham and Women’s Hospital reported new observational data showing 

 infections to originate in the hospital were especially rare during the first wave of the pandemic in the US.

Over 12 weeks from March-May 2020, the investigators traced just 2 COVID-19 cases to nosocomial origin.

 by Chanu Rhee, MD, MPH, Assistant Professor at Harvard Medical School, provide clinical evidence for a series of rigorous infection control practices applied in the Boston hospital. They may also inform institutions in COVID-19 hotspots or those at continued risk of institution outbreaks.

 during IDWeek, Rhee provided context into his team’s findings, what practices Brigham and Women’s put in place at the beginning of the pandemic, and how such measures can inform both hospitals and other community settings attempting to mitigate COVID-19 spread.

Prior to research, what was our working theory or understanding of nosocomial COVID-19 infection among hospitals in the early days of outbreak?

In the early days of the pandemic, there were reports of widespread outbreaks of SARS-CoV-2 within skilled nursing facilities and other congregate settings. However, little was known about nosocomial SARS-CoV-2 infection among patients in acute care hospitals. As such, there was a lot of anxiety about whether the infection control measures recommended by the CDC were adequate to prevent spread within the hospital and many patients have foregone essential medical care due to fear of contracting COVID-19.

What observed measures were put into place to manage COVID-19 hospital spread?

At our hospital, the core components of our infection control program included the following:

Screening of all patients for COVID-19 symptoms on admission and daily thereafter

Requiring all hospital staff to attest to the presence or absence of symptoms prior to starting their shift; staff with symptoms are referred for COVID-19 testing and not allowed to work if symptoms are present

Liberal use of PCR testing initially for all symptomatic patients on admission or with any new symptoms during hospitalization. In late April we implemented universal testing for all patients at the time of admission, including asymptomatic patients.

Dedicated COVID-19 units with airborne infection isolation rooms.

Personal protective equipment (PPE) in accordance with CDC recommendations.

Universal masking of staff and subsequently patients and visitors

Restriction of visitors except in extenuating circumstances

We also developed hospital-wide protocols on when clinicians were permitted to discontinue isolation precautions in patients with suspected COVID-19, which generally required 2 negative RT-PCR tests at least 12 hours apart, and used protocols based on CDC-guidance to determine when patients with confirmed COVID-19 could be released from isolation.

How did this research better inform infection control measures and resourcing?

COVID-19 presents many infection control challenges since many infected individuals are asymptomatic yet contagious; current diagnostic tests are imperfect, especially if patients are tested too early in the incubation period; and transmission can occur through multiple mechanisms including droplets, fomites, and aerosols. Our analysis, however, demonstrates that a multifaceted infection control program based on US CDC guidance can minimize the risk of nosocomial transmission of SARS-CoV-2.

Over the first 12 weeks of the pandemic, our hospital cared for over 9000 patients including nearly 700 with COVID-19. Despite the high burden of COVID-19 in our hospital, we only identified 2 patients who likely acquired their infection in the hospital, including one who was most likely infected by his spouse prior to visitor restrictions and universal masking.

Adversely—given the rarity of hospital spread when such measures are applied—what can other community settings at risk of significant spread take away from these findings?

While our study cannot determine which interventions are most important to prevent spread of COVID-19, my take-away is that a comprehensive program is needed to minimize the risk. In other words, there is no one silver bullet.

One important observation that emerged from our case reviews was that several patients were only tested for the first time three or more days after hospitalization, sometimes because of atypical symptoms that were initially attributed to non-COVID conditions. These cases highlighted the importance of implementing universal testing on admission, and we observed fewer late-onset cases after this intervention. However, universal testing is not infallible as several patients initially tested negative while asymptomatic and then tested positive after symptoms began several days later. This underscores the fact that PCR can miss some infections early in the incubation period.

Another important theme that emerged from our case reviews was the need to conduct serial testing of patients with clinical syndromes highly suspicious for COVID-19. At least three cases with concerning syndromes initially tested negative but were positive on repeat testing. Based on our early experience, we instituted a protocol requiring at least 2 negative RT-PCR tests in symptomatic patients before discontinuing isolation.

Are there any plans for continued or follow-up research?

In addition to the analysis presented in the study, which encompassed the period from March 7 – May 30, we have continued to closely monitor our hospital for any new potential cases of nosocomial SARS-CoV-2 infection. We found no additional cases of nosocomial infection over the ensuing months. However, in late September we did have a cluster of SARS-CoV-2 infections that occurred on two units in our hospital that affected both patients and staff. More information can be found on our website 

Our investigation determined that the cluster likely began with a highly contagious patient who initially tested negative twice on admission. With a combination of pre-emptive precautions, intense contact tracing, and serial testing of all patients and staff associated with the affected units, and numerous other measures, we have been able to fully contain this cluster. We are currently evaluating the lessons learned from the cluster to determine how best to further improve our infection control policies moving forward.

The study, “Incidence of Nosocomial COVID-19 in Patients Hospitalized at a Large U.S. Academic Medical Center,” was presented at IDWeek 2020.

Articles

The hospital found just 2 cases in their first 12 weeks were borne in the facility. A study author provides insight.

Brigham and Women's Provides Blueprint for Hospital COVID-19 Protection

New data from a University of Kentucky-based multi-disciplinary opioid use disorder (OUD) referral system presented at 

more than 60% of eligible patients with OUD

 who originally presented with injection drug use-associated infection (IDU-AI) cases for care of their addiction.

The program has been anecdotally beneficial for continual drug-abuse patients with HIV, hepatitis C virus (HCV), and other chronic conditions who continually present at inpatient care settings for IDU-AI.

What does the ideal care team look like for this cross-specialty novel program?

 during IDWeek, Sarah Blevins, PharmD, an HIV Clinical Pharmacist with University of Kentucky, discussed her team’s unique makeup across infectious disease and addiction medicine—as well as a reliable collaboration with the university’s leading experts.

“We have an extraordinary addictions team at the University of Kentucky, and they are supportive,” Blevins said. “They’re there when we have questions, and when we need to run across tough cases, and we have that support from them.”

Blevins also discussed what next steps for the program may entail: a patient satisfaction questionnaire may inform add-on addiction medicine offerings, and there’s consideration toward adding a peer support expert to the team.

Greater hopes for such a program would be in eventual long-term data showing such a referral system is benefitting hospital admission rates, and mitigating regional issues including spiked methamphetamine abuse rates.

Watch the full interview with Blevins in the video above.

A cross-specialty collaboration to mitigate inpatient cases of opioid use disorder has had early success; developers want to grow it.

Improving on an Infectious Disease Referral Program for Addiction Care

 from a randomized, open-label assessment presented at 

 at risk of ventilation needs had benefitted significantly from intravenous immunoglobulin (IVIG).

Study author George Sakoulas, MD, Associate Professor at University of California San Diego, presented the findings showing 3 times daily IVIG plus pre-infusion solumedrol 40 mg was associated with significantly reduced risk of mechanical ventilation, lengthier intensive care unit (ICU) stay, and shorter hospital stay.

So, as investigators undergo a phase 3 trial, why hasn’t the therapy candidate been discussed more?

 during IDWeek, Sakoulas discussed how immunoglobulin’s mechanism as both a neutralizing and “immune-signaling” molecule resulted in its observed benefit versus COVID-19’s observed vascular, inflammatory effects in patients.

The care team pursued further research only on the basis of anecdotal success and their review of retrospective data from China.

“It’s interesting,” Sakoulas said. “Surprisingly, it was not explored early on.”

Though the therapy is not an antiviral agent, Sakoulas highlighted potential long-term—and even improved—benefits.

“Going forward, as more people become blood donors by which IVIG is derived, we’re going to see some neutralized antibodies emerge in the products, and we may even have a second benefit of antiviral effects in the product,” he said.

Listen to the full interview with Sakoulas in the video above.

An investigator shares detail into how the neutralizing, immune-signaling molecule may provide continued success against the virus.

How Does IV Immunoglobulin Work for COVID-19?

 care, therapy research and development is so rapid that it’s difficult for scientists to not face the cold reality of hindsight on a near-daily basis; so often and so quickly does clinical understanding of the pandemic update that direction is constantly changing, strategies are constantly refining.

A virtual panel discussion hosted at IDWeek 2020 drove home that message for at least one participant this week.

Ravina Kullar, PharmD, MPH, an infectious disease pharmacist and epidemiologist, and founder of duXsana, discussed her involvement in the IDWeek panel aptly titled “Challenging Cases in COVID-19: Through Fire and Water.”

The event subjected a group of infectious disease experts to a series of difficult COVID-19 patient case studies in real-time, requiring their collaboration to establish appropriate care. What stood out to Kullar was realizing some cases from as far back as March of this year relied heavily on antiviral therapies now undervalued for COVID-19: hydroxycholoroquine and remdesivir, to name a few.

“It really had most of us take a step back and realize how far we have come from the beginning of this pandemic, when we thought one agent may have worked,” Kullar told 

. “We have learned so much during just the months we have been in this pandemic.”

In an interview during IDWeek, Kullar discussed the panel and its ability to highlight marked change in a short period of time during COVID-19. Though some of it emphasized the chaotic and sometimes failed early response to the pandemic, Kullar herself saw the great strides made by a vast and collaborative network of researchers in such short time.

“I think the silver lining here is that in just 10 months into this pandemic, science has come such a long way,” Kullar said. “Scientists have been working long and hard to get good data out in a record time."

Ravina Kullar, PharmD, MPH, reflects on rapid advances in COVID-19 treatment understanding during IDWeek 2020.

COVID-19 Case Studies: How Far Science Has Come

Investigators have observed an association between the prevalence of 

 in higher hospital levels, and greater rates of antibiotic use, suggesting the need for improved anti-MRSA antibiotic prescribing benchmarks.

, showed that across 122 Veterans Health Administration (VHA) hospitals during 2016, median days of therapy (DOT) with anti-MRSA antibiotics 96.5 (IQR, 81.1 - 116.9) per 1000 days present, versus 562.1 (IQR, 505.9 - 631.6) DOT with total antibiotics per 1000 days present.

A hospital-level risk-adjusted analysis showed hospital MRSA prevalence was significantly associated with monthly anti-MRSA and total antibiotic prescribing (IRR, 1.05 and 1.02, respectively).

“A 5% increase in the hospital’s MRSA prevalence was associated with an increase in the monthly use of anti-MRSA antibiotics and total antibiotics by 23.6 and 8.3 DOT per 1,000 days-present, respectively,” investigators wrote.

 during IDWeek, study author Daniel J. Livorsi, MD, MSc, Assistant Professor at the University of Iowa Carver College of Medicine, discussed his team’s findings and their implication for antibiotic stewardship needs.

“I think the other challenge is the way that stewardship teams generally interact with prescribers has changed as well,” he said. “We’re trying to discourage face-to-face conversations, and that’s often a good way to give feedback. If we’re trying to minimize doing that, we have to reconsider how we do stewardship.”

Watch the full interview with Livorsi in the video above.

The study, “Association of MRSA Prevalence and Hospital-level Antibiotic Use: A Retrospective Study Across 122 Acute-care Hospitals,” was presented at IDWeek 2020.

New data suggest collaboration between hospital prescribers and stewardship teams is still not perfected.

Hospital Antibiotic Prescribing Linked to MRSA Prevalence

New data from the VA showed there’s been a broad increase in antibiotic prescribing this year, coinciding with the initial surge of 

The new data, presented at IDWeek 2020, showed the pandemic’s overwhelming costs were able to abruptly reverse the course of four-plus years in steadied antibiotic prescribing.

Investigators concluded in their research that there may be myriad reasons for the increase of antibiotic use during the pandemic: be it increased patient vulnerability and provider treatment uncertainties, inappropriately decreased provider thresholds for initiating or continuing therapy, or stresses on the structure and staffing of antimicrobial stewardship programs.

Regardless of the reason, there is an inherent sense of frustration that a bit of the slowly developed antimicrobial stewardship foundation has become harmed by this, a still little understood viral infection which has consumed the attention of the entire infectious disease field.

during IDWeek, study author Matthew Goetz, MD, Chief of Infectious Diseases at VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, discussed the findings, the possible causes of return to antibiotic over-prescribing during COVID-19, resolutions being made to the spike, and what future research may entail.

“Frankly, physicians had no validated treatments and were really anxious to do something that might help patients, and antibiotics were those tools,” Goetz said.

Watch the full interview with Goetz in the video above.

The study, “Antimicrobial Use in the Time of COVID-19 – Data from 84 VA Facilities,” was presented at IDWeek 2020.

New data show the pandemic, and a lack of efficacious therapies, did harm to 4 years' worth of stewardship.

Antibiotic Prescribing Increased in VA Clinics During COVID-19 Spread


For patients taking integrase inhibitors (INSTIs), there have been reports of spontaneous metabolic effects.

The US Food and Drug Administration (FDA) has its publicly available database, the FDA Adverse Event Reporting System (FAERS), which captures these adverse events.

Investigators decided to analyze these data to determine if rare or unknown events were something clinicians should be more concerned about.

The investigators reviewed FAERS data from the fourth quarter of 2007 through the fourth quarter of 2019. They only included adults in the review, which consisted of over 10.1 million reports. The countries with the most frequent events was the United States, United Kingdom, and Japan.

“The Standardized MedDRA Query (SMQ) for hyperglycemia/new onset diabetes mellitus (H/DM) was used to identify metabolic adverse events of interest,” the investigators wrote. “Weight gain was defined as increased weight or increased BMI and was analyzed as a separate event. Reporting odds ratios (ROR) and 95% Confidence Intervals (CIs) were calculated for the INSTI class and for individual agents.”

H/DM was noted in 732591 reports (7.2%) and 109566 (1.1%) reported weight gain.

“Any INSTI was mentioned as a primary and/or secondary suspect agent in 18400 (0.18%) reports (bictegravir: 1414 [0.01%]; dolutegravir: 7840 [0.08%]; elvitegravir: 4034 [0.04%]; raltegravir: 5,551 [0.05%]). RORs (95% CI) for H/DM and weight gain for any INSTI were 1.20 (1.15, 1.27) and 2.16 (1.96, 2.38),” the investigators reported. “For individual agents, RORs (95% CI) for H/DM and weight gain were bictegravir: 1.23 (1.10, 1.37) and 6.82 (5.50, 8.41); dolutegravir: 1.28 (1.19, 1.39) and 1.86 (1.58, 2.18); elvitegravir: 0.76 (0.56, 1.02) and 1.63 (1.37, 1.92); raltegravir: 1.00 (0.90, 1.11) and 3.29 (2.77, 3.91). H/DM was noted in 159 bictegravir and 712 dolutegravir reports.”

This study, “META-INSTI: Metabolic Adverse Events Following Integrase Strand Transfer Inhibitor Administration in Spontaneous Adverse Event Reports,” was presented as an oral abstract at IDWeek 2020.

Milena Murray, PharmD, MSc, BCIDP, AAHIVP is an associate professor of Pharmacy Practice

Midwestern University College of Pharmacy, and an HIV/ID clinical pharmacist at Northwestern Memorial Hospital in Downers Groove, IL. She is a presenting author of the study and spoke to 

What was your motivation for doing this study?


My team published a case report regarding INSTI induced hyperglycemia. I wanted to look at the problem with a broader lens.

What are the important takeaways from it?


So far, all INSTIs are associated with weight gain, whereas a few of the agents are associated with hyperglycemia. Clinically, patients taking INSTI therapy should have their weight and blood glucose regularly monitored.


We are planning to analyze the hyperglycemic events to see if there are any interactions with metformin.


INSTIs are a mainstay of therapy for most people living with HIV. Many patients are now aware of these metabolic side effects and more data are needed to be able to appropriately guide therapy and counsel patients.

Investigators wanted to examine spontaneously reported adverse events and whether they were cause for concern. 

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