Michael Calderwood, MD, MPH
@CalderwoodMD
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Infectious Diseases Physician, Chief Quality Officer @DHMCandClinics, Associate Professor of Medicine @GeiselMed
Hanover, NH
Joined October 2014
I love these two slides on the evidence for combination therapy in persistent MRSA and MSSA bacteremia. References in footer of each slide. #IDWeek2024
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1/8 Preview of revised @IDSAInfo Complicated UTI Guidelines, including simpler definition ("infection beyond the bladder"). Men CAN have an uncomplicated UTI.
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Dear PCPs: Please stop prescribing hydroxychloroquine for patients to have at home “just in case” they get COVID-19. This is depleting the supply for patients who actually get sick.
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A colleague just sent me this and I had to share.
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1/4 After OVIVA trial, there is increasing comfort with early switch to oral antibiotics for a wide range of bone and joint infections: Here is a nice table on oral bioavailability presented at #IDWeek2022. Note agents with rifampin interaction.
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In a retrospective cohort study at 12 hospitals (2017-2019), 25,560 out of 35,415 (72%) patients who received antibiotics within 3hrs of SIRS did not meet “true sepsis” definition. These “overtreated” patients had longer LOS and higher rates of C diff.
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36% reduction in urine cultures (although trending down before intervention) and 36% reduction in antibiotic use with no change in LOS, transfer to higher level of care, or mortality using BLADDER score in work-up of potential UTI.
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SABATO trial - Non-inferior outcomes switching to oral therapy after 5-7 days of IV therapy in treatment of low-risk S aureus bloodstream infection (see exclusions).
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Great discussion on differing guidelines for how long to treat LTBI before starting anti-TNF therapy in IBD patients at #IDWeek2024.
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More is not always better. Adding vancomycin to cefazolin as surgical prophylaxis in patients undergoing arthroplasty does not improve outcomes in patients not known to be MRSA colonized. Outcomes WORSE for knee arthroplasty. Just don't. #IDWeek2024.
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The FDA posted materials yesterday on the efficacy and safety of the Pfizer vaccine: If helpful to others, here are my summary notes.
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Combination therapy with daptomycin for Staphylococcus aureus bacteremia. Three paper shared at #IDWeek2021. Nice table below. The answer seems to be NO.
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“Overdiagnosis and overtreatment of [Lyme disease] is worsening, and health authorities should investigate this phenomenon.” 75% patients in this study of patients seeking treatment for chronic Lyme disease were IgG negative.
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Fascinating study discussed at #IDWeek2024. Four different clinical phenotypes for S aureus bacteremia. Highest mortality in A, lower mortality in B and E, microbiologic outcomes worse in C (with adjunctive rifampicin benefit seen in C).
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1/8 Let's talk New Hampshire. We need to have an honest dialogue about how bad things are right now with #COVID19. We currently are averaging more cases per day than at any point in the pandemic (66x higher than last summer). @SteveAhnen @NHHospitals @NHMedSociety @DartmouthHitch
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Another nail in the vancomycin coffin. After accounting for laboratory testing, pharmacist management time, and costs associated with vancomycin associated AKI, daptomycin saved $166 per patient when used in place of vancomycin.
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Nice real world data from NY showing that while #COVID19 vaccine protection against laboratory-confirmed infection has fallen from 92 ➡️ 80%, protection against hospitalization remains 92-95%. #BelieveInData
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Thank you @ShiraDoronMD @ElissaPerkins @BranchWestyn for their well written Op Ed on why it is time to move away from mask mandates in school. This is a follow-up to one written 2-3 weeks ago.
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Poster 218 at #IDWeek2018: Want to pay for an ID pharmacist. One year of IV-to-PO conversions at Parkland Health and Hospital System (~1800 interventions) saved over a half million dollars in costs.
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Want to make it easy for providers to NOT prescribe antibiotics for asymptomatic bacteriuria? Try this dot phrase shared at #SHEASpring2023.
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Poster 1062 at #IDWeek2018: Just because we can doesn’t mean we should. Increasing trend in ceftaroline/daptomycin use over vancomycin for MRSA bacteremia. This study showed no benefit in time to negative BCx and overall mortality.
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Sepsis requires early identification and intervention. but there are many mimickers. h/t to Dr. Chanu Rhee @BrighamWomens @DeptPopMed #IDWeek2019
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“Vaccinated individuals with recurrent #COVID19 have a significantly shorter duration of infectivity, lower viral loads, and earlier negativisation [of] rapid antigen detection test.”
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1/10 Most influential infection prevention papers presented at #IDWeek2022 (non-COVID). 1. In >300 HCP caring for monkeypox patients, only 23% wore all recommended PPE, yet no HCP infections in 21 days. Risk of transmission in health care settings is low.
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"10 minutes after taking a shower, the entire shower room is contaminated with bacteria that were in the shower drain." #SHEASpring2023.
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Osteomyelitis Complicating Sacral Pressure Ulcers: Systematic review found little evidence for treatment longer than 2 weeks in the absence of debridement and wound closure. Nice follow-up here: and here:
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1/2 To treat empyema, guidelines give duration recommendations of 2-6 weeks, with most patients receiving 3-4 weeks in clinical practice. RCTs suggest that okay to stop at 2 weeks if clinically stable. #IDWeek2024.
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Amazing work by Rochester Regional Health presented at #SHEA2019. Love the idea of a DeCATHlon: hand hygiene hurdles, device utilization dash, appropriate culturing long jump.
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Initial micafungin treatment does not improve outcomes compared to fluconazole treatment in immunocompromised and critically ill patients with candidaemia - Challenges the dogma. #IDWeek2024
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44% of physician clothing and 38% of physician shoes were culture-positive for healthcare-associated pathogens. How often are you washing your fleece vest? Do you ever wash your tie? Should I burn my shoes? Poster 441. #SHEA2018.
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Dear @MedicareGov @CMSGov, please start paying for IV antibiotics at home. Requiring that my patients go to a SNF, if otherwise eligible for home discharge, does not improve outcomes. In fact, this paper argues the exact opposite.
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1/2 Dr. Shruti Gohil @UCIrvineHealth presented INSPIRE data on intra-abdominal infections (IAIs) at #IDWeek2024. IAIs involve diverse organs/spaces. Yet, only 1% (+) for MRSA and another 1% (+) for Pseudomonas, despite 63% of patients getting empiric broad-spectrum abx treatment.
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STOP-CDI Trial from UPenn presented at #IDWeek2024: Solid-organ transplant, autologous stem cell transplant, CART, and leukemia admissions screened for C diff colonization. Triggered contact precautions and prophylactic PO Vanco. 79% reduced odds of HO-CDI (and reduced LOS)!
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I would like to thank @DartmouthHitch for the opportunity to serve as Chief Quality Officer for our academic medical center. I am truly lucky to work with a team of amazing colleagues improving patient care each and every day.
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Over 6 months, close to 300 antibiotic timeouts were conducted by 12 female pharmacists and 8 male pharmacists @UofUHealth. Physicians appeared more likely to accept recommendations made by male pharmacists. Suggests possible #GenderBias. #SHEASpring2022
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With a map like this, it seems like it is time to say goodbye to the Z-pack everywhere in the U.S. for CAP.
With the new CAP guidelines recommending macrolide monotherapy only in areas with pneumococcal resistance <25%, please consider alternatives as resistance is quite high across the US.
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Nice study demonstrating reduced incidence of new Gram-negative resistance longitudinally in hospitalized patients with sepsis who had their antibiotic de-escalated to something less broad spectrum.
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Need another reason not to treat asymptomatic bacteriuria? No you don’t, but here it is. Nitrofurantoin use in the 12 weeks prior to C diff associated with 2-fold risk of multiple recurrent infections.
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In women 65 and older, using a cut off of 10 WBCs/uL on urinalysis has a sensitivity of 100% but a specificity of 36% for UTI, while increasing this to 200 WBCs/uL improves specificity to 86% with a sensitivity of 89%. See table 3:
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Can we all agree that the Z-pack is dead as monotherapy for community acquired pneumonia? Hey urgent care centers…please stop time prescribing if you actually want to help patients. And by the way, cefpodoxime and doxycycline aren’t great either.
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ID eConsults associated with 70% decreased odds of 30 day mortality (p 0.003) and trend toward lower 30 day readmission (p 0.07), with 95% “very satisfied” by consult and no increase in transfers. #NeedMoreID @IDSAInfo
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As I did for the Pfizer vaccine, here is my summary of the data for the Moderna vaccine. The FDA posted materials here:
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At a 5% risk of hospitalization, the estimated number needed to treat to prevent one hospitalization was 24 for Paxlovid (nirmatrelvir/ritonavir) - $12,700, 25 for sotrovimab - $52,500, 28 for remdesivir - $52,416, and 50 for molnupiravir - $35,000.
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I walked into a store last weekend wearing a mask. The owner kindly let me know that masks were optional but that she would happily put one on if it made me more comfortable. I was comfortable removing my mask, but this simple exchange exemplified the human kindness that we need.
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Need something catchy for a push to reduce inappropriate urine cultures. Some ideas include:.1. Say no to the flow.2. If there ain’t no pain, don’t obtain.3. Don’t fall victim, ask about a symptom.Which do you like? Other ideas?.
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42% mortality reduction in MRSA bacteremia cases treated with combination ceftaroline/daptomycin compared with vancomycin. What if we started with this therapy and then tailored to monotherapy when clinically improving?
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Donut story in “Diagnostic Clinical Cases” at #IDWeek2021: Surgeon sends a nice piece of tissue to pathology and a single swab to microbiology asking for every possible culture. Microbiologist asks the surgeon if he would like a donut and then swabs the donut and gives that. 🤣.
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In patients with a prosthetic joint who develop bacteremia, 1 out of 5 with a Staph/Strep bacteremia end up with a PJI (while 4 out of 5 do not) and 1-2 out of 100 with a GNR bacteremia end up with a PJI.
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I am excited to have received my first #CovidVaccine @DartmouthHitch to save lives and end this pandemic. It will take the willingness of many rolling up their sleeves and getting vaccinated for us to finally hang up our masks, gather together, and start the process of healing.
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For those who already have or are in the process of switching to Area Under the Curve (AUC) dosing for vancomycin, this paper looks at nephrotoxicity in those on the higher end of the 400-600 range.
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Among providers seeing patients both in person and via telehealth, odds of prescribing an antibiotic was 1.7x higher following a telehealth visit. Physical exam and face-to-face counseling matter.
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1 in 5 patients diagnosed with sinusitis in the U.S. from 2016-2020 were prescribed azithromycin - not recommended for sinusitis. And 75% of patients prescribed first-line therapy were prescribed >7 days - not recommended.
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Poster 229 at #IDWeek2020: Hospital medicine attendings given “scorecards” showing rank order of antibiotic DOT/1,000 patient days, % IV vs PO, and % of patients prescribed pip-tazo for >3 days. 73% improved their antibiotic prescribing. Love this!.
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Nice poster on C diff testing algorithm by team from @NorthwesternMed presented at #IDWeek2022. Poster 180.
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Another plea for @CMSGov (Medicare) to cover home IV antibiotics. Requiring an individual to go to a SNF who could otherwise go home is madness and particularly dangerous at a time when long term care facilities are struggling with COVID-19.
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C. difficile cases that are PCR positive but toxin negative are 80% less likely to recur. Many of these likely reflect colonization rather than infection.
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Stop the madness (post-op antibiotic prophylaxis) says Westyn Branch-Elliman @IDWeek2018. Antibiotics after skin closure don’t reduce risk of SSI but increases risk of both AKI and CDI in a linear fashion. AKI risk highest with vancomycin.
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Impact of #COVID19 on Hospitalized Patients: “Restrictions…regarding visits/companions exerted a negative impact…increasing the patients' feelings of loneliness/isolation. Negative impacts also evidenced in the hospital admission and discharge process.”
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When treating a susceptible UTI with cephalexin, BID dosing is equivalent to QID dosing when measuring treatment failure and recurrence.
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Happy 12th birthday to my daughter! Posted with permission from my children. #VaccinesWork #VaccinesAreSafe #COVID19
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Rejoice for waste reduction. “Glove and gown use for all patient contact in medical and surgical ICUs did not result in a reduction in the acquisition of C. difficile compared with usual care.”
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Poster 625 at #SHEASpring2023: Do you have FOMO (fear of missing organisms)? If your patient with a diabetic foot infection has not had a culture with Pseudomonas in the past year, this has a negative predictive value of 94%. Hold on the pip-tazo!.
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Want to safely reduce length of stay among patients admitted with community acquired pneumonia? Switch to oral antibiotics earlier! Huge opportunity in US hospitals.
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Another study showing that discontinuing contact precautions for MRSA does NOT increase the incidence of MRSA or…of whole genome sequencing confirmed transmission. Toss tie & white coat, roll up sleeves, wash your hands, and clean your stethoscope.
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My PCP recently shared this quote: “Most machines if not working well, will run better if unplugged for a few minutes and then plugged back in, including you.” Sharing for those who need to hear this.
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Poster 241 at #IDWeek2020: Of >670k women w/ uncomplicated UTI, 47% of abx written for inappropriate agents, 76% for inappropriate durations. Excess durations > in rural locations. Follow-up tough when pts need to drive hrs to be seen. Role for telemedicine to assist stewardship?.
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I wasn’t expecting this. ”Patients treated for a UTI through a virtual visit were more likely to receive a first-line antibiotic agent (74.9% vs 59.4%; P = .002) and guideline-concordant duration (100% vs 53.1%; P < .001).”
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Providers find it difficult not to treat once they have a positive U/A or UCx, independent of whether it was appropriate to test and when they know the evidence doesn’t show a benefit in treating asymptomatic bacteriuria. Goal needs to be reducing testing.
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Forget #BetterCallSaul, #COVID19 has unleashed "Better Call Infection Prevention." Poster at #SHEASpring2021 by @uihealthcare reports on 500% increase in calls to infection prevention. Planning for future emergencies needs to include solutions to increase IP response capacity.
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We are getting news today on the Johnson and Johnson vaccine: A different headline focuses on severe infection: I am attaching a quick summary on how I am messaging about this vaccine to colleagues.
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This is cool. Beta-lactams (particularly nafcillin/oxacillin and cefazolin) are better than vancomycin for MSSA bacteremia. This paper demonstrates differences in key cytokine signaling pathways while on these different antibiotics.
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A lot of talk re: stricter U/A reflex criteria to reduce inappropriate urine culturing, but how about doing away with any reflex culturing and sending urine cultures based on symptoms? Just remember, mental status change, urine odor, and urine color are NOT indications. #SHEA2019.
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For all who are interested in the future of Infectious Diseases as a specialty, I highly recommend reading this article: Table 1 has seven actionable recommendations.
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Great article on "Rethinking Carbapenems" for necrotizing pancreatitis.
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WHO would like to remind everyone that drinking alcohol will not protect you from coronavirus - Many parents requesting a multi-armed randomized controlled trial. 😀
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Expenditures for outpatient parenteral abx on the rise. As IV abx not needed in 34-41% of these cases, consult ID!
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Urinary catheters placed by medical students in the OR have a 4-fold higher rate of CAUTIs than those placed by nurses. Most of these students will not be placing urinary catheters in their future careers. Why do they need this “experience”?
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1/3 I was asked to give an overview of infection prevention and control. Here is a quick review of some of the history behind this amazing field. #MedicalHistory @SHEA_Epi @APIC
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Clifford McDonald: “C. diff is a clinical diagnosis. No lab test alone can make the diagnosis.” #SHEA2018.
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58% of infectious diseases confronted by humanity worldwide have been at some point aggravated by climatic hazards . 1,006 unique pathways in which climatic hazards lead to pathogenic diseases. #IDWeek2023
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I am going to sign off tonight with this…it really upsets me when stores post a sign saying “mask use preferred” and half of the people in the store refuse to wear a mask. It is about respect for your community.
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Love this. Our fellows have begun using AUC-based dosing calculators. It leads to less insane initial doses and lower risk of nephrotoxicity. As discussed in the abstract link below, a large number of patients achieved therapeutic targets with vancomycin troughs of 10-15.
In #IDWeek2018 poster 1415, @SIDPharm member Dr. Jamie Kisgen shares his team's experience with development and implementation of a dosing calculator for AUC-based dosing of vancomycin. w/@SIDPharm member Dr. Megan Seddon et al.
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Tedizolid was used as suppressive antimicrobial therapy for knee, hip, and shoulder PJI in 17 patients for a median of 6 months with no hematologic, neurological, or GI adverse effects. 9 of these patients had previously had adverse effects from linezolid.
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Digging into the ID doc data presented: 2020 saw a 31% ⬆️ in paperwork/administration, an average of 60 hrs/week worked, an 18% ⬆️ in patients seen/week, a 14% ⬇️ in feeling fairly compensated, YET 89% say they would choose ID again.
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So, how is each state doing in terms of % of population 65+, 18-64, and 12-17 with 70%+ vaccination (green), 50-69% vaccination (yellow), and <50% vaccination (red)? There is a lot to dissect here, but I am glad that I live in New England! #COVID19
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Remember work is only part of life. We are multi-dimensional beings. There will be days when work fills your wings, days when family and friends fill your wings, days when you are the wind, and days when someone needs to catch you as you fall. Enjoy each of them. Life is short.
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While I miss in person conferences, making homemade blueberry muffins with late season berries picked last weekend helps to enjoy #IDWeek2021 from home.
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Many have discontinued standard contact precautions for patients with MRSA and VRE. In the setting of PPE shortages during #COVID19, team @StLukesHealthTX discontinued isolation for MRSA/VRE with NO increase in hospital-acquired MRSA/VRE infections. #SHEASpring2021.
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ID fellows are starting to look for jobs and to arrange interviews at #IDWeek2018. If you know of open positions or the best places to look for academic and non-academic positions around the country, please reply.
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