Systematic review of piperacillin-induced neutropenia.

Because penicillin agents are implicated in granulopoiesis inhibition, healthcare professionals frequently consider discontinuation of such therapy in patients with decreasing white blood cell counts. No systematic review to date has described piperacillin and the patient population at risk for this adverse drug reaction (ADR).This review sought to assess the occurrence of piperacillin-induced neutropenia, describe characteristics of affected patients and assess the reporting modalities that most accurately classify this ADR. Case reports, cohort studies and clinical trials identified by comprehensive searches of PubMed and the US FDA Adverse Event Reporting System (AERS) database were reviewed for patient demographics, duration and dose of piperacillin or piperacillin-tazobactam treatment and the occurrence of neutropenia. Causality assessments were performed.Six published case reports, three cohort studies, 178 clinical trials and two compilations of phase I-III trials were reviewed. Review of case reports was notable in that the duration of beta-lactam therapy prior to the noting of leukopenia always exceeded 15 days. No deaths were recorded in this group. Among 13,816 patients enrolled in non-neutropenic fever studies, the occurrence of piperacillin-induced neutropenia was rare: five patients (0.04%) developed neutropenia; none died. The demographics for this group were poorly documented. Through the AERS database, we identified 366 unique cases of piperacillin or piperacillin-tazobactam-induced haematological abnormalities, including neutropenia (n = 183, 50.0%), leukopenia, (n = 99, 27%), agranulocytosis (n = 58, 15.8%) and others. In 62 cases, patients received between 1 and 14 days of therapy (mean 7.7 + 4.1 days). Overall, there were 82 (22.4%) deaths.Reports of haematological ADRs among patients receiving piperacillin or piperacillin-tazobactam are rare. Report of neutropenia associated with piperacillin usage prior to 15 days of therapy is a novel finding that requires further evaluation. Current reporting methods poorly characterise patient groups at risk.     

Observation of Hand Hygiene Practices in Home Health Care

ObjectiveTo describe nurse hand hygiene practices in the home health care (HHC) setting, nurse adherence to hand hygiene guidelines, and factors associated with hand hygiene opportunities during home care visits.DesignObservational study of nurse hand hygiene practices.Settingand Participants: Licensed practical/vocational and registered nurses were observed in the homes of patients being served by a large nonprofit HHC agency.MethodsTwo researchers observed 400 home care visits conducted by 50 nurses. The World Health Organization's “5 Moments for Hand Hygiene” validated observation tool was used to record opportunities and actual practices of hand hygiene, with 3 additional opportunities specific to the HHC setting. Patient assessment data available in the agency electronic health record and a nurse demographic questionnaire were also collected to describe patients and nurse participants.ResultsA total of 2014 opportunities were observed. On arrival in the home was the most frequent opportunity (n = 384), the least frequent was after touching a patient's surroundings (n = 43). The average hand hygiene adherence rate was 45.6% after adjusting for clustering at the nurse level. Adherence was highest after contact with body fluid (65.1%) and lowest after touching a patient (29.5%). The number of hand hygiene opportunities was higher when patients being served were at increased risk of an infection-related emergency department visit or hospitalization and when the home environment was observed to be “dirty.” No nurse or patient demographic characteristics were associated with the rate of nurse hand hygiene adherence.Conclusions and ImplicationsHand hygiene adherence in HHC is suboptimal, with rates mirroring those reported in hospital and outpatient settings. The connection between poor hand hygiene and infection transmission has been well studied, and it has received widespread attention with the outbreak of SARS-CoV-2. Agencies can use results found in this study to better inform quality improvement initiatives.     

Voriconazole therapeutic drug monitoring in allogeneic hematopoietic stem cell transplant recipients

Voriconazole, a new antifungal agent, is increasingly being used after HSCT. The hepatic cytochrome P450 isoenzyme 2C19 plays a significant role in voriconazole metabolism. As CYP2C19 exhibits significant genetic polymorphism, some patients metabolize voriconazole poorly resulting in increased plasma drug levels. The clinical significance of this is unknown, and the utility of monitoring voriconazole levels is unclear. Steady-state trough plasma voriconazole levels were obtained in 25 allogeneic HSCT recipients using an HPLC assay. Patients had drug levels checked once (n=13), twice (n=10), or > or =3 times (n=2) 5-18 days (median 10) after starting voriconazole or dose modification. The 41 voriconazole levels were 0.2-6.8 microg/ml (median 1.6); 6 (15%) were <0.5 (possibly below the in vitro MIC90 for Aspergillus spp.). Voriconazole concentrations correlated with aspartate aminotranferase (AST) (r=0.5; P=0.0009) and alkaline phosphatase (r=0.34; P=0.03), but not with creatinine, bilirubin and alanine aminotransferase (ALT). Since liver dysfunction is common after HSCT, it was not possible to determine if elevated AST and alkaline phosphatase levels were the cause or the consequence of higher voriconazole levels. We conclude that trough voriconazole levels vary considerably between patients, and suggest monitoring levels in patients receiving voriconazole for confirmed fungal infections, and in those with elevated AST or alkaline phosphatase levels.     

Individual,social, and environmental factors for infection risk among home healthcare patients: A multi-method study

There has been limited research into the individual, social, and environmental factors for infection risk among patients in the home healthcare (HHC) setting, where the infection is a leading cause of hospitalisation. The aims of this study were to (1) explore nurse perceptions of individual, social, and environmental factors for infection risk among HHC patients; and (2) identify the frequency of environmental barriers to infection prevention and control in HHC. Data were collected in 2017–2018 and included qualitative interviews with HHC nurses (n = 50) and structured observations of nurse visits to patients' homes (n = 400). Thematic analyses of interviews with nurses suggested they perceived infection risk among patients as being influenced by knowledge of and attitudes towards infection prevention and engagement in hygiene practices, receipt of support from informal caregivers and nurse interventions aimed at cultivating infection control knowledge and practices, and the home environment. Statistical analyses of observation checklists revealed nurses encountered an average of 1.7 environmental barriers upon each home visit. Frequent environmental barriers observed during visits to HHC patients included clutter (39.5%), poor lighting (38.8%), dirtiness (28.5%), and pets (17.2%). Additional research is needed to clarify inter-relationships among these factors and identify strategies for addressing each as part of a comprehensive infection control program in HHC.     

“A catalyst for action”: Factors for implementing clinical risk prediction models of infection in home care settings

ObjectiveThe study sought to outline how a clinical risk prediction model for identifying patients at risk of infection is perceived by home care nurses, and to inform how the output of the model could be integrated into a clinical workflow.Materials and MethodsThis was a qualitative study using semi-structured interviews with 50 home care nurses. Interviews explored nurses’ perceptions of clinical risk prediction models, their experiences using them in practice, and what elements are important for the implementation of a clinical risk prediction model focusing on infection. Interviews were audio-taped and transcribed, with data evaluated using thematic analysis.ResultsTwo themes were derived from the data: (1) informing nursing practice, which outlined how a clinical risk prediction model could inform nurse clinical judgment and be used to modify their care plan interventions, and (2) operationalizing the score, which summarized how the clinical risk prediction model could be incorporated in home care settings.DiscussionThe findings indicate that home care nurses would find a clinical risk prediction model for infection useful, as long as it provided both context around the reasons why a patient was deemed to be at high risk and provided some guidance for action.ConclusionsIt is important to evaluate the potential feasibility and acceptability of a clinical risk prediction model, to inform the intervention design and implementation strategy. The results of this study can provide guidance for the development of the clinical risk prediction tool as an intervention for integration in home care settings.