Use of Novel Strategies to Develop Guidelines for Management of Pyogenic Osteomyelitis in Adults: A WikiGuidelines Group Consensus Statement.

Importance Traditional approaches to practice guidelines frequently result in dissociation between strength of recommendation and quality of evidence. Objective To construct a clinical guideline for pyogenic osteomyelitis management, with a new standard of evidence to resolve the gap between strength of recommendation and quality of evidence, through the use of a novel open access approach utilizing social media tools. Evidence Review This consensus statement and systematic review study used a novel approach from the WikiGuidelines Group, an open access collaborative research project, to construct clinical guidelines for pyogenic osteomyelitis. In June 2021 and February 2022, authors recruited via social media conducted multiple PubMed literature searches, including all years and languages, regarding osteomyelitis management; criteria for article quality and inclusion were specified in the group's charter. The GRADE system for evaluating evidence was not used based on previously published concerns regarding the potential dissociation between strength of recommendation and quality of evidence. Instead, the charter required that clear recommendations be made only when reproducible, prospective, controlled studies provided hypothesis-confirming evidence. In the absence of such data, clinical reviews were drafted to discuss pros and cons of care choices. Both clear recommendations and clinical reviews were planned with the intention to be regularly updated as new data become available. Findings Sixty-three participants with diverse expertise from 8 countries developed the group's charter and its first guideline on pyogenic osteomyelitis. These participants included both nonacademic and academic physicians and pharmacists specializing in general internal medicine or hospital medicine, infectious diseases, orthopedic surgery, pharmacology, and medical microbiology. Of the 7 questions addressed in the guideline, 2 clear recommendations were offered for the use of oral antibiotic therapy and the duration of therapy. In addition, 5 clinical reviews were authored addressing diagnosis, approaches to osteomyelitis underlying a pressure ulcer, timing for the administration of empirical therapy, specific antimicrobial options (including empirical regimens, use of antimicrobials targeting resistant pathogens, the role of bone penetration, and the use of rifampin as adjunctive therapy), and the role of biomarkers and imaging to assess responses to therapy. Conclusions and Relevance The WikiGuidelines approach offers a novel methodology for clinical guideline development that precludes recommendations based on low-quality data or opinion. The primary limitation is the need for more rigorous clinical investigations, enabling additional clear recommendations for clinical questions currently unresolved by high-quality data

Shaping the Future of Infectious Diseases: The Journey to Promote Value, Opportunity, and Positive Messaging

The field of infectious diseases (ID) offers a rewarding career path and is widely viewed as an essential subspecialty in medicine. However, in recent years, these positive aspects have been overshadowed by concerns surrounding low fellowship match rates, undercompensation, and burnout. The Infectious Diseases Society of America Fellowship Training Program Directors Committee met in 2023, discussed the future of ID as a specialty, and sought to develop strategies to highlight the value and opportunities of ID for future generations, as well as underscore the importance of and provide tools for positive messaging to trainees about the subspecialty. This paper presents ideas generated at this meeting and is meant to serve as a reference for ID training program directors, as well as the wider ID community, in uplifting and shaping the future of the field

Risk Factors Associated With Nephrotoxicity During Outpatient Intravenous Vancomycin Administration

Background: Many studies have described an association between intravenous vancomycin and nephrotoxicity; however, the majority have evaluated incidence and risk factors among hospitalized patients. Outpatient administration of intravenous antibiotics is a growing practice and presents its own set of unique challenges. Objective: The aim of this study was to identify risk factors for vancomycin-associated nephrotoxicity in the outpatient setting. Methods: A case-control study of patients who received intravenous vancomycin through an Outpatient Parenteral Antimicrobial Therapy (OPAT) program was conducted. Patients were identified who developed an acute kidney injury (AKI) during treatment. The primary outcome was the incidence of AKI during treatment. Results: A total of 37 out of 130 patients (28.5%) met the criteria for AKI. AKI was more likely to occur in patients with a longer duration of therapy, higher maximum trough concentration, co-administration of a fluoroquinolone or metronidazole, and those who received another potentially nephrotoxic medication. Co-administration of a fluoroquinolone (OR = 5.96, P = 0.009, [CI: 1.59, 24.38]), any nephrotoxic medication (OR = 11.17, P &lt; 0.001, [CI 3.14, 51.23]), and a higher maximum vancomycin trough (OR = 1.29, P &lt; 0.001, [CI 1.17, 1.44]) were all indicative of a higher odds of an AKI. Conclusion: In this cohort, vancomycin-associated nephrotoxicity was common during outpatient intravenous antibiotic therapy. Co-administration of a fluoroquinolone, any nephrotoxic medication, and a higher maximum vancomycin trough were associated with AKI development. Further study is needed to determine how this impacts long-term clinical outcomes and what measures can be taken to reduce nephrotoxicity risk. </jats:p

Clinical Outcomes in Hospitalized Patients with COVID-19 on Therapeutic Anticoagulants

ABSTRACTBackgroundCOVID-19 is associated with hypercoagulability and an increased incidence of thrombosis. We evaluated the clinical outcomes of adults hospitalized with COVID-19 who either continued therapeutic anticoagulants previously prescribed or who were newly started on anticoagulants during hospitalization.MethodsWe performed an observational study of adult inpatients’ with COVID-19 at 10 hospitals affiliated with Northwestern Medicine in the Chicagoland area from March 9 to June 26, 2020. We evaluated clinical outcomes of subjects with COVID-19 who were continued on their outpatient therapeutic anticoagulation during hospitalization and those who were newly started on these medications compared to those who were on prophylactic doses of these medications based on the World Health Organization (WHO) Ordinal Scale for Clinical Improvement. The primary outcome was overall death while secondary outcomes were critical illness (WHO score ≥5), need for mechanical ventilation, and death among those subjects who first had critical illness adjusted for age, sex, race, body mass index (BMI), Charlson score, glucose on admission, and use of antiplatelet agents.Results1,716 subjects with COVID-19 were included in the analysis. 171 subjects (10.0%) were continued on their outpatient therapeutic anticoagulation and 201(11.7%) were started on new therapeutic anticoagulation during hospitalization. In subjects continued on home therapeutic anticoagulation, there were no differences in overall death, critical illness, mechanical ventilation, or death among subjects with critical illness compared to subjects on prophylactic anticoagulation. Subjects receiving new therapeutic anticoagulation for COVID-19 were more likely to die (OR 5.93; 95% CI 3.71-9.47), have critical illness (OR 14.51; 95% CI 7.43-28.31), need mechanical ventilation (OR 11.22; 95% CI 6.67-18.86), and die after first having critical illness. (OR 5.51; 95% CI 2.80 −10.87).ConclusionsContinuation of outpatient prescribed anticoagulant was not associated with improved clinical outcomes. Therapeutic anticoagulation for COVID-19 in absence of other indications was associated with worse clinical outcomes.</jats:sec