Pub Date : 2023-11-29eCollection Date: 2023-11-01DOI: 10.3138/jammi-2022-0042
Bernard Ho, Sahana Kukan, Warren McIsaac
Background: Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting.
Methods: This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics.
Results: Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%-18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]).
Conclusions: The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.
背景:抗菌素耐药性是一种世界范围的现象,导致大量不必要的死亡和昂贵的住院费用。超过90%的抗生素使用发生在社区,其中,家庭医生占这些处方的三分之二。我们的研究旨在确定家庭医学居民是否在初级保健环境中对常见传染病的抗生素处方进行了最佳培训。方法:本研究是对安大略省多伦多市中心两个城市初级保健诊所抗菌药物管理的先前研究的二次分析。2015年至2016年间,共有1099名成人患者就诊,涉及家庭医学住院医师实习生。主要观察指标为各病种的住院抗生素处方率和专家推荐处方做法、延迟开具处方率和一线推荐窄谱抗生素的使用情况。结果:与专家推荐的处方率相比,家庭医学居民在无并发症上呼吸道感染(URI) (5.0% [95% CI 2.2%至9.7%],专家推荐为0%)和鼻窦炎(44.2% [95% CI 32.8%至55.9%],专家范围为11%-18%)和肺炎(53.5% [95% CI 37.7%至68.8%],专家范围为100%)的处方率过高。咽炎(28.6% [95% CI 16.6% ~ 43.3%])、支气管炎(3.6% [95% CI 0% ~ 18.4%])和膀胱炎(79.4% [95% CI 70.6% ~ 86.6%])的处方率均在专家推荐范围内。结论:家庭医学住院医师在培训期间的抗生素处方实践表明,一些常见感染的抗生素处方过量。建议对加拿大初级保健培训项目中的抗生素处方进行进一步研究,以确定未来的家庭医生是否正在学习适当的抗生素处方实践。
{"title":"Do family medicine residents optimally prescribe antibiotics for common infectious conditions seen in a primary care setting?","authors":"Bernard Ho, Sahana Kukan, Warren McIsaac","doi":"10.3138/jammi-2022-0042","DOIUrl":"10.3138/jammi-2022-0042","url":null,"abstract":"<p><strong>Background: </strong>Antimicrobial resistance is a worldwide phenomenon that leads to a significant number of unnecessary deaths and costly hospital admissions. More than 90% of antibiotic use happens in the community and of this, family physicians account for two-thirds of these prescriptions. Our study aims to determine whether family medicine residents are optimally trained in antibiotic prescribing for common infectious conditions seen in a primary care setting.</p><p><strong>Methods: </strong>This study is a secondary analysis of a prior study of antimicrobial stewardship in two urban primary care clinics in central Toronto, Ontario. A total of 1099 adult patient visits were included that involved family medicine resident trainees, seen between 2015 and 2016. The main outcome measures were resident antibiotic prescription rates for each condition and expert-recommended prescribing practices, the rate prescriptions were issued as delayed prescriptions, and the use of first-line recommended narrow-spectrum antibiotics.</p><p><strong>Results: </strong>Compared to expert-recommended prescribing rates, family medicine residents overprescribed for uncomplicated upper respiratory tract infections (URI) (5.0% [95% CI 2.2% to 9.7%] versus 0% expert recommended) and sinusitis (44.2% [95% CI 32.8% to 55.9%] versus 11%-18% expert range), and under prescribed for pneumonia (53.5% [95% CI 37.7% to 68.8%] versus 100% expert range]). Prescribing rates were within expert recommended ranges for pharyngitis (28.6% [95% CI 16.6% to 43.3%]), bronchitis (3.6% [95% CI 0% to 18.4%]), and cystitis (79.4% [95% CI 70.6% to 86.6%]).</p><p><strong>Conclusions: </strong>The antibiotic prescribing practices of family medicine residents during their training programs indicated overprescribing of antibiotics for some common infection presentations. Further study of antibiotic prescribing in primary care training programs across Canada is recommended to determine if future family physicians are learning appropriate antibiotic prescribing practices.</p>","PeriodicalId":19454,"journal":{"name":"Official Journal of the Association of Medical Microbiology and Infectious Disease Canada","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10697098/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"84863072","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-29eCollection Date: 2023-11-01DOI: 10.3138/jammi-2023-0001
Patrick Dolcé, Annie de Beaumont-Dupont, Philippe Jutras, Florence Mailhot-Léonard, Maria Alexandra Rosca, Joanne Aubé-Maurice
Background: The lower Saint Lawrence river region (LSLRR), in Quebec, has a 10-fold higher incidence of Q fever compared to the provincial rate. This study aimed to review clinical cases and the Q fever risk exposure in this region.
Methods: Data were retrieved from microbiology laboratory, medical records from Rimouski Regional Hospital and Public Health reports between 1991 and 2018. They were analyzed with Epi Info 7.2.2.6. Patients with confirmed acute, probable acute, and chronic Q fever were classified using standard case definitions and mapped according to the postal code, to assess the correlation between cases and sheep distribution.
Results: Out of 295 cases, 258 were included (241 confirmed acute, seven probable acute, 10 chronic). Median age was 49 years, 76% were male. For acute cases, the prominent symptoms were fever (99%), headache (83%), chills (80%), sweating (72%), myalgia (69%), and fatigue (67%). Clinical presentation was mostly febrile syndrome with mild hepatitis (84%). A seasonal peak was observed from May to July (56% of acute cases). Most cases (56%) occurred within the two counties where sheep production was highest. Exposure to sheep was prominent 93%, including 64% direct contact (15% shepherds, 49% sheepfold visitors), 14% indirect contact, and 15% sheepfold neighbors.
Conclusions: To our knowledge, this is one of the largest retrospective studies of Q fever cases reported in Canada. Q fever in Quebec LSLRR is associated mainly with sheep exposure. Fever and hepatitis were the most common manifestations. Preventive measures should be considered in this region to protect sheepfold workers, visitors, and their neighbors.
背景:魁北克省圣劳伦斯河下游地区(LSLRR)的Q热发病率比全省高10倍。本研究旨在回顾该地区的临床病例和Q热风险暴露情况。方法:数据来源于微生物实验室、Rimouski地区医院1991 - 2018年的医疗记录和公共卫生报告。使用Epi Info 7.2.2.6进行分析。使用标准病例定义对确诊的急性、可能急性和慢性Q热患者进行分类,并根据邮政编码绘制地图,以评估病例与绵羊分布之间的相关性。结果:共纳入295例病例258例(确诊急性241例,疑似急性7例,慢性10例)。中位年龄49岁,76%为男性。急性病例的主要症状为发热(99%)、头痛(83%)、发冷(80%)、出汗(72%)、肌痛(69%)和疲劳(67%)。临床表现多为发热综合征伴轻度肝炎(84%)。5月至7月为季节性高峰(56%的急性病例)。大多数病例(56%)发生在羊产量最高的两个县。与羊的接触占93%,其中直接接触占64%(牧羊人占15%,羊圈游客占49%),间接接触占14%,羊圈邻居占15%。结论:据我们所知,这是加拿大报道的Q热病例中最大的回顾性研究之一。魁北克LSLRR的Q热主要与绵羊接触有关。发热和肝炎是最常见的表现。该地区应考虑采取预防措施,保护羊圈工作人员、访客及其邻居。
{"title":"The lower Saint Lawrence River region of Quebec, a hot spot for sheepfold-associated Q fever in Canada: Review of 258 cases.","authors":"Patrick Dolcé, Annie de Beaumont-Dupont, Philippe Jutras, Florence Mailhot-Léonard, Maria Alexandra Rosca, Joanne Aubé-Maurice","doi":"10.3138/jammi-2023-0001","DOIUrl":"10.3138/jammi-2023-0001","url":null,"abstract":"<p><strong>Background: </strong>The lower Saint Lawrence river region (LSLRR), in Quebec, has a 10-fold higher incidence of Q fever compared to the provincial rate. This study aimed to review clinical cases and the Q fever risk exposure in this region.</p><p><strong>Methods: </strong>Data were retrieved from microbiology laboratory, medical records from Rimouski Regional Hospital and Public Health reports between 1991 and 2018. They were analyzed with Epi Info 7.2.2.6. Patients with confirmed acute, probable acute, and chronic Q fever were classified using standard case definitions and mapped according to the postal code, to assess the correlation between cases and sheep distribution.</p><p><strong>Results: </strong>Out of 295 cases, 258 were included (241 confirmed acute, seven probable acute, 10 chronic). Median age was 49 years, 76% were male. For acute cases, the prominent symptoms were fever (99%), headache (83%), chills (80%), sweating (72%), myalgia (69%), and fatigue (67%). Clinical presentation was mostly febrile syndrome with mild hepatitis (84%). A seasonal peak was observed from May to July (56% of acute cases). Most cases (56%) occurred within the two counties where sheep production was highest. Exposure to sheep was prominent 93%, including 64% direct contact (15% shepherds, 49% sheepfold visitors), 14% indirect contact, and 15% sheepfold neighbors.</p><p><strong>Conclusions: </strong>To our knowledge, this is one of the largest retrospective studies of Q fever cases reported in Canada. Q fever in Quebec LSLRR is associated mainly with sheep exposure. Fever and hepatitis were the most common manifestations. Preventive measures should be considered in this region to protect sheepfold workers, visitors, and their neighbors.</p>","PeriodicalId":19454,"journal":{"name":"Official Journal of the Association of Medical Microbiology and Infectious Disease Canada","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10697106/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"82139990","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-11-29eCollection Date: 2023-11-01DOI: 10.3138/jammi-2022-0014
Jennifer Tat, Sigmund Krajden, Samir N Patel, Greg J German
Bacteremia is a rare finding among Clostridioides difficile infections. We describe a case of a 67-year-old man with resected colorectal cancer with colostomy who presented with small bowel obstruction and was admitted for lysis of adhesions. On day 8 of admission, he developed leukocytosis and raised inflammatory markers with isolation of Gram-positive bacilli in several blood cultures, which was presumptively identified through blood culture pelleting and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) as C. difficile. The diagnosis was confirmed with conventional culture and reference lab identification and the patient demonstrated clinical response with parenteral then oral vancomycin that briefly worsened when therapy was switched to parenteral metronidazole and then improved once oral vancomycin was resumed. Our case was notable in that the combination of pelleting and MALDI-TOF offered early diagnosis in this patient whose positive blood cultures were suspicious for contamination and in whom there was an absence of diarrheal illness or features of colitis on abdominal imaging. Early diagnosis is critical for the timely initiation of therapy, implementation of infection prevention and control measures and in selection of appropriate therapy for antimicrobial stewardship.
{"title":"Early diagnosis of monomicrobial <i>Clostridioides difficile</i> bacteremia in a patient without colitis.","authors":"Jennifer Tat, Sigmund Krajden, Samir N Patel, Greg J German","doi":"10.3138/jammi-2022-0014","DOIUrl":"10.3138/jammi-2022-0014","url":null,"abstract":"<p><p>Bacteremia is a rare finding among <i>Clostridioides difficile</i> infections. We describe a case of a 67-year-old man with resected colorectal cancer with colostomy who presented with small bowel obstruction and was admitted for lysis of adhesions. On day 8 of admission, he developed leukocytosis and raised inflammatory markers with isolation of Gram-positive bacilli in several blood cultures, which was presumptively identified through blood culture pelleting and matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) as <i>C. difficile</i>. The diagnosis was confirmed with conventional culture and reference lab identification and the patient demonstrated clinical response with parenteral then oral vancomycin that briefly worsened when therapy was switched to parenteral metronidazole and then improved once oral vancomycin was resumed. Our case was notable in that the combination of pelleting and MALDI-TOF offered early diagnosis in this patient whose positive blood cultures were suspicious for contamination and in whom there was an absence of diarrheal illness or features of colitis on abdominal imaging. Early diagnosis is critical for the timely initiation of therapy, implementation of infection prevention and control measures and in selection of appropriate therapy for antimicrobial stewardship.</p>","PeriodicalId":19454,"journal":{"name":"Official Journal of the Association of Medical Microbiology and Infectious Disease Canada","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-11-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10697101/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72565792","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-18eCollection Date: 2023-09-01DOI: 10.3138/jammi-2022-0031
JeongMin Marie Kim, Cesilia Nishi, Jennifer Mina Grant
Background: Acyclovir has an important role in the treatment of viral central nervous system (CNS) infection, especially herpes simplex virus (HSV)-1 encephalitis. It is therefore used broadly as empiric therapy for many patients who present to the hospital with symptoms of a possible neurologic infection. We sought to review our practices in acyclovir prescribing, deprescribing, and associated investigations for the clinical syndromes it treats.
Methods: Through a retrospective chart review, we identified patients prescribed acyclovir for a possible CNS infection upon admission to Vancouver General Hospital between January 1, 2019, and December 31, 2019. Patient demographics, signs, symptoms, and comorbidities were taken from admission consultation notes or discharge summaries; their investigations, including laboratory tests and imaging, were also recorded. The primary purpose was to describe the appropriateness of empiric acyclovir use in suspected meningoencephalitis cases.
Results: Among the 108 patients treated with acyclovir, 94 patients had an indication for starting empiric treatment for encephalitis or meningitis. There was suspicion and workup for encephalitis alone in 76 patients. Among discharge diagnoses, the most common was delirium of a different identified source (18 cases), followed by unknown/other (15 cases). There were seven patients whose CSF viral PCR test was positive for HSV or varicella-zoster virus (VZV); three of them had HSV-1 encephalitis. There were two total adverse events recorded attributed to acyclovir; both cases were of mild acute kidney injury.
Conclusion: We found that in many patients, acyclovir was not necessary or could have been stopped earlier, avoiding toxicity and drug costs.
{"title":"A retrospective review of empiric acyclovir prescribing practices for suspected viral central nervous system infections: A single-centre study.","authors":"JeongMin Marie Kim, Cesilia Nishi, Jennifer Mina Grant","doi":"10.3138/jammi-2022-0031","DOIUrl":"10.3138/jammi-2022-0031","url":null,"abstract":"<p><strong>Background: </strong>Acyclovir has an important role in the treatment of viral central nervous system (CNS) infection, especially herpes simplex virus (HSV)-1 encephalitis. It is therefore used broadly as empiric therapy for many patients who present to the hospital with symptoms of a possible neurologic infection. We sought to review our practices in acyclovir prescribing, deprescribing, and associated investigations for the clinical syndromes it treats.</p><p><strong>Methods: </strong>Through a retrospective chart review, we identified patients prescribed acyclovir for a possible CNS infection upon admission to Vancouver General Hospital between January 1, 2019, and December 31, 2019. Patient demographics, signs, symptoms, and comorbidities were taken from admission consultation notes or discharge summaries; their investigations, including laboratory tests and imaging, were also recorded. The primary purpose was to describe the appropriateness of empiric acyclovir use in suspected meningoencephalitis cases.</p><p><strong>Results: </strong>Among the 108 patients treated with acyclovir, 94 patients had an indication for starting empiric treatment for encephalitis or meningitis. There was suspicion and workup for encephalitis alone in 76 patients. Among discharge diagnoses, the most common was delirium of a different identified source (18 cases), followed by unknown/other (15 cases). There were seven patients whose CSF viral PCR test was positive for HSV or varicella-zoster virus (VZV); three of them had HSV-1 encephalitis. There were two total adverse events recorded attributed to acyclovir; both cases were of mild acute kidney injury.</p><p><strong>Conclusion: </strong>We found that in many patients, acyclovir was not necessary or could have been stopped earlier, avoiding toxicity and drug costs.</p>","PeriodicalId":19454,"journal":{"name":"Official Journal of the Association of Medical Microbiology and Infectious Disease Canada","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10795701/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"86327760","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2023-09-18eCollection Date: 2023-09-01DOI: 10.3138/jammi-2022-0019
Sunil Samnani, Helen Bibby, LeeAnne Luft
Background: We report a case of a 47-year-old male presenting with Yersinia enterocolitica septicemia with no known risk factors for invasive infection, found to have multiloculated liver and splenic abscesses with an antecedent history of mild enterocolitis.
Case presentation: Our patient presented with septic shock in the setting of gastroenteritis with abdominal pain and fever. On work-up, he was found to have multiloculated hepatic and splenic abscesses secondary to Y. enterocolitica. No identifiable risk factors (ie, iron-overload syndrome or immunosuppression) for Y. enterocolitica septicemia were identified in our patient. Our patient was treated with a prolonged course of antibiotics until imaging resolution of his liver and splenic abscesses.
Conclusion: Invasive Y. enterocolitica in an immunocompetent host is rare. Our case highlights the pathogenicity of Y. enterocolitica, and important treatment and management considerations.
{"title":"Brief report of complicated <i>Yersinia enterocolitica</i> infection in an immunocompetent host: Review of the literature and pathogenicity mechanisms.","authors":"Sunil Samnani, Helen Bibby, LeeAnne Luft","doi":"10.3138/jammi-2022-0019","DOIUrl":"10.3138/jammi-2022-0019","url":null,"abstract":"<p><strong>Background: </strong>We report a case of a 47-year-old male presenting with <i>Yersinia enterocolitica</i> septicemia with no known risk factors for invasive infection, found to have multiloculated liver and splenic abscesses with an antecedent history of mild enterocolitis.</p><p><strong>Case presentation: </strong>Our patient presented with septic shock in the setting of gastroenteritis with abdominal pain and fever. On work-up, he was found to have multiloculated hepatic and splenic abscesses secondary to <i>Y. enterocolitica</i>. No identifiable risk factors (ie, iron-overload syndrome or immunosuppression) for <i>Y. enterocolitica</i> septicemia were identified in our patient. Our patient was treated with a prolonged course of antibiotics until imaging resolution of his liver and splenic abscesses.</p><p><strong>Conclusion: </strong>Invasive <i>Y. enterocolitica</i> in an immunocompetent host is rare. Our case highlights the pathogenicity of <i>Y. enterocolitica</i>, and important treatment and management considerations.</p>","PeriodicalId":19454,"journal":{"name":"Official Journal of the Association of Medical Microbiology and Infectious Disease Canada","volume":null,"pages":null},"PeriodicalIF":0.0,"publicationDate":"2023-09-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10795698/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"73667420","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}