Algorithm could help detect patients who are likely to have antibiotic allergic-type reactions

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IV drip by hospital bed In a study published today in JAMA Network Open, US researchers report that a newly developed algorithm demonstrated high sensitivity in detecting antibiotic allergic-type reactions in patients receiving antibiotic prophylaxis (prevention) for cardiac implantable electronic device (CIED) procedures.

In the retrospective study, researchers analyzed data on Veterans Affairs (VA) patients who had undergone CIED procedures and received peri-procedural antibiotic prophylaxis from October 2015 through September 2019. The aim of the study was to develop and test a set of electronic health record variables that could indicate allergic-type reactions to the antibiotics typically used to prevent surgical-site infections. The lack of systematic surveillance for antibiotic drug reactions in this context prevents clinicians from getting real-time feedback about potential patient harms.

The cohort of 36,344 patients included 34,703 CIED procedures with antibiotic exposures (mean age, 72 years; 98% male patients). The median duration of post-procedural prophylaxis was 4 days.

The final algorithm model included seven variables as potential factors for allergic-type reaction: entries in the VA hospitals' Allergy Reaction Tracking (ART) system, either historic (odds ratio [OR], 42.37; 95% confidence interval [CI], 11.33 to 158.43) or observed (OR, 175.10; 95% CI, 44.84 to 683.76); PheCodes for "symptoms affecting skin" (OR, 8.49; 95% CI, 1.90 to 37.82), "urticarial" (OR, 7.01; 95% CI, 1.76 to 27.89), and "allergy or adverse event to an antibiotic" (OR, 11.84, 95% CI, 2.88 to 48.69); keyword detection in clinical notes (OR, 3.21; 95% CI, 1.27 to 8.08); and antihistamine administration alone or in combination (OR, 6.51; 95% CI, 1.90 to 22.30).

These findings highlight the importance of perioperative antibiotic stewardship to limit harms of unnecessary antibiotic exposures and the need for innovative strategies.

The model identified antibiotic allergic-type reactions with an estimated probability of 30% or more. The positive predictive value was 61% (95% CI, 45% to 76%) and sensitivity was 87% (95% CI, 70% to 96%). The most frequently administered antibiotics with allergic-type reactions included cephalosporins (40%) and vancomycin (23%).

"These findings highlight the importance of perioperative antibiotic stewardship to limit harms of unnecessary antibiotic exposures and the need for innovative strategies to provide audit and feedback to clinicians about patient harm caused by unnecessary antibiotic exposures," the study authors wrote.

Study: Death rates in COVID ICU patients 69% higher than for flu

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Stephanie Soucheray, MA

ICU sign A new nationwide French study comparing outcomes for patients in the intensive care unit (ICU) for either influenza or COVID-19 due to acute respiratory failure shows that COVID-19 patients had a longer hospital stay and a 69% higher mortality rate than ICU patients with influenza. The study was published yesterday in the Journal of Infection.

The study compared outcomes, including death and the need for mechanical ventilation, among COVID-19 patients hospitalized at any point from March 1, 2020, to June 30, 2021, and influenza patients seen from January 1, 2014, to December 31, 2019. A total of 105,979 COVID-19 patients were compared to 18,763 influenza patients.

The authors found patients with influenza seen in the ICU required more invasive mechanical ventilation (47% vs 34%), but patients with COVID-19 were 69% more likely to die during their hospital stay (25% vs 21% of patients; (adjusted hazard ratio, 1.69; 95% confidence interval, 1.63 to 1.75).

Critically ill COVID-19 patients were more likely to be men with comorbidities and were slightly younger than critically ill influenza patients. Thirty percent of COVID-19 patients seen in the ICU were under the age of 60.

"The type of comorbidities differed between the two populations," the authors explained. "Arterial hypertension [high blood pressure], diabetes mellitus, chronic kidney disease, and solid tumour were more frequent in COVID-19 patients, while congestive heart disease, chronic respiratory disease, cirrhosis, and malignancies were more frequent in influenza patients."

Only 5% of symptomatic COVID-19 patients required admission to the ICU for acute respiratory failure in this study, which is one of the largest studies focused on comparing COVID-19 with influenza patient outcomes in the ICU, the author said. But the 69% higher mortality rate persisted event after COVID-19 vaccines were widely available in early 2021.

UK reports fatal enterovirus-linked myocarditis cluster in newborns

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Lisa Schnirring

The United Kingdom has reported an unusual increase in myocarditis infections and two deaths in babies who had enterovirus infections, the World Health Organization (WHO) said yesterday.

In early April, the UK notified the WHO about an increase in severe myocarditis in infants in Wales. Fifteen cases consistent with neonatal sepsis in babies 28 days old and younger were reported from Wales and Southwest England from June 2022 and March 2023. Polymerase chain reaction (PCR) testing in nine patients confirmed either coxsackie B3 or coxsackie B4. As of April, three patients were hospitalized, four were receiving outpatient care, and two died.

The WHO said though enterovirus infections are common in young babies, the link to myocarditis with severe outcomes in the group is unusual. For comparison, in the hospital in South Wales that treated 10 of the cases only treated one similar case in the previous 6 years.

Myocarditis, or inflammation of the heart muscle, was the presenting feature, and cases peaked in November 2022, with sporadic cases reported across the other months. Enterovirus infections are typically mild, but they can be more severe in newborns than in older children.

An incident management team is reviewing all the evidence and has alerted UK authorities, who have raised awareness among health providers about the enterovirus cluster. Epidemiologic investigations are still under way. Also, clinicians published a letter detailing eight of the cases last month in BMJ.