Steven Tong Profile picture
Apr 25, 2022 9 tweets 3 min read Read on X
@AchimKaasch about to present SABATO results at #ECCMID2022! Image
SABATO has been going on for quite a while now!

Question: is switching to oral therapy for low risk SAB possible?

Low risk: negative follow-up BC, no mestatistic infection, intravascular catheters removed, no prosthetic vascular material, not immunosuppressed
Benefits and risks: Image
Design: Image
Study meds:
Reasonable choices, but noting that trimethoprim-sulfa inferior to vanc in Paul et al study for MRSA. Image
CONSORT diagram: Image
Ended up with smallish numbers still - 108 in oral and 105 in IV arms.

Baseline characteristics:
Only 5% MRSA. Line related infections about 60%.
Results:

No difference between treatment arms.
Certainly no difference in per protocol populations which the presentation focussed on.
Wasn't clear in presentation what the pre-defined non-inferiority margin was. If 5% then in the ITT may not have been NI. Image
Have looked at the trial protocol. The NI margin was intially 5% but then in the updated protocol increased to 10%. So looks like it meets the NI margin of 10% in the ITT for the primary outcome of SAB related complication in 90d: 0.007 (-0.078 to 0.091).

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More from @syctong

Oct 21, 2022
Follow-up BC in GN BSI
Majdi N. Al-Hasan

Gianella CMI 2020. Lower mortality in those who had follow-up BC done -> 2 fold reduction.

Maskarinec CMI 2020. 1702 patients. FUBC in 68%. 20% FUBC persistently positive. Higher mortality if no FUBC. If done, FUBC+ higher mortality
I haven't read the studies, but do wonder about both immortal time bias and bias by indication in these studies. Is there something systematically different in those who do get FUBC?
Amipara EClinicalMedicine 2021
766 patients. Excluded if died within 72h. Propensity score adjustment

If FUBC not done, higher mortality. About 0.5 hazard ratio.

So the above 3 studies, consistently found 2 fold decline in mortality if FUBC done.
Read 5 tweets
Oct 21, 2022
At #IDWeek2022

Role of follow-up blood cultures for Gram positives
Valeria Fabre

Detection of bacteria depends on:
Volume of blood and number of sets - should aim 40ml in 4 bottles (2 sets)
About 20% of GP bactermia are persistent. Mostly S. aureus. Strep not persistent. Wiggers BMC ID 2016

Persistance in SAB may occur in up to 40% of cases
Minejima CID 2020 mentioned again. @BradSpellberg
Risk factors for prolonged SAB - MRSA, endovascular source, ICU

Bacteremia of ≥3 days independent predictor of 30-day mortality
Read 9 tweets
Oct 21, 2022
Detecting the cefazolin inoculum effect with a rapid test. #IDWeek2022

Sara I. Gomez Villegas, MD; @SuperBugDoc

When S. aureus MIC to cefazolin increases in vitro when inoculum increased

Prevalence 3-15%

Retrospective studies find CzIE associated with poorer outcomes
Looking at dataset from pediatric OM
250 MSSA with 14.4% CzIE+. These were associated with progression from acute to chronic OM

Gold standard for detection is BMD. Cumbersome test. 3 days for test.
CzIE+ isolates release more BlaZ enzyme. Nitrocefin changes colour in the presence of B-lactamase

Novel 3 hr assay to detect CzIE

Aim: evaluate accuracy of nitrocefin test
Read 6 tweets
Oct 21, 2022
ACTIV-1 infliximab, abatacept and cenicriviroc (CVC) as immunomodulators in COVID-19. Emily Ko

#IDWeek22

COVID-19 with pneumonitis / hypoxia

Primary endpoint - time to recovery

Ages 55, 60% male, BMI 32, 50% obese

Receiving remdesivir and steroids, <10% IMV
Infliximab - about 500 in active and placebo arms; no diff in time to recovery. 41% lower odds of day 28 mortality, 32% higher odds of clinical status at day 14.
No diff in adverse events
Abatacept - about 500 in active and placebo; no diff in time to recovery, Reduced odds of day 28 mortality. No diff in adverse events, with slightly higher bacterial infections (not stats sig).
Read 4 tweets
Oct 21, 2022
Getting ready for Clinical Controversies in treatment of S. aureus bacteremia. #IDWeek2022 Image
Increasing recognition that 'persistent' bacteremia should probably be earlier rather than later. Each day longer, associated with increased metastatic complications and mortality.
What is best treatment? ASP or cefazolin? Issues of increased toxicity vs cefazolin inoculum effect.
>>> we need to test in a clinical trial

If still BC+ at 5 days?
No routine role for combination antibiotics - no benefit with rifampin, daptomycin, aminoglycosides in trials
Read 23 tweets
Oct 21, 2022
Debating role of vancomycin for MRSA at #IDWeek2022.

Dr Wagner argues that increasing duration of MRSA bacteraemia associated with poorer outcomes (mortality).

I accept this.

BUT, therapeutically reducing duration of bacteraemia has not been associated with improved mortality.
Duration of bacteremia is a SURROGATE. Although logical and biologically plausible that reducing duration of bacteremia with a particular antibiotic (vs another) should improve the outcome we care about (mortality), this has not yet been demonstrated.
Cites 43% of patients with trough-based dosing develop AKI.

We didn't find this in CAMERA2. Almost all on vanc and trough-based dosing. In control arm only 6% developed AKI. jamanetwork.com/journals/jama/…

Yes, that was in the context of a clinical trial. But 6% is far from 43%
Read 4 tweets

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