Notes Financial support. Research in the Mulvey lab is funded by the National Institutes of Health (grant number AI095647). Potential conflicts of interest. Both authors: No reported conflicts. Both authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Amelia E. Barber and Matthew A. Mulvey Department of Pathology, Division of Microbiology and Immunology, University of Utah School of Medicine, Salt Lake City
References 1. Kaye D, Sobel JD. Persistence of intracellular bacteria in the urinary bladder. Clin Infect Dis 2014; 58:444. 2. Barber AE, Norton JP, Spivak AM, Mulvey MA. Urinary tract infections: current and emerging management strategies. Clin Infect Dis 2013; 57:719–24. 3. Dhakal BK, Kulesus RR, Mulvey MA. Mechanisms and consequences of bladder cell invasion by uropathogenic Escherichia coli. Eur J Clin Invest 2008; 38(suppl 2):2–11. 4. Schilling JD, Lorenz RG, Hultgren SJ. Effect of trimethoprim-sulfamethoxazole on recurrent bacteriuria and bacterial persistence in mice infected with uropathogenic Escherichia coli. Infect Immun 2002; 70:7042–9. 5. Kerrn MB, Struve C, Blom J, Frimodt-Moller N, Krogfelt KA. Intracellular persistence of Escherichia coli in urinary bladders from mecillinam-treated mice. J Antimicrob Chemother 2005; 55:383–6. 6. Blango MG, Mulvey MA. Persistence of uropathogenic Escherichia coli in the face of multiple antibiotics. Antimicrob Agents Chemother 2010; 54:1855–63. 7. Bower JM, Eto DS, Mulvey MA. Covert operations of uropathogenic Escherichia coli within the urinary tract. Traffic 2005; 6: 18–31. 8. Rosen DA, Hooton TM, Stamm WE, Humphrey PA, Hultgren SJ. Detection of intracellular bacterial communities in human urinary tract infection. PLoS Med 2007; 4: e329. 9. Khasriya R, Sathiananthamoorthy S, Ismail S, et al. Spectrum of bacterial colonization associated with urothelial cells from patients with chronic lower urinary tract symptoms. J Clin Microbiol 2013; 51:2054–62. Correspondence: Matthew A. Mulvey, PhD, Room 2520, EEJMRB, Pathology Department, University of Utah, 15 N Medical Drive E, #2100, Salt Lake City, UT 84112-5650 (
[email protected]). Clinical Infectious Diseases 2014;58(3):444–5 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.
[email protected]. DOI: 10.1093/cid/cit706
Internet-Based Institutional Antimicrobial Stewardship Program Resources in Leading US Academic Medical Centers TO THE EDITOR—We read with great interest the article by Moodley et al [1], which presents a review of infectious diseases applications (apps) for the iPhone/iPad and Android devices. The authors detail
numerous resources and discuss potential opportunities to optimize app reliability or standardization, which is of value to a wide range of specialists. The purpose of this letter is to elaborate on the theme of accessible electronic resources by providing data on Internet-based institutional antimicrobial stewardship program (ASP) web pages from leading American academic medical centers. We utilized online search engines to analyze hospitals listed as University HealthSystem Consortium (UHC) members [2] to identify the existence of hospital and health-system ASP web pages. UHC is an alliance of hospitals representing the nation’s leading academic medical centers. Existence and components of institutionspecific ASP online resources were recorded. To identify potentially prototypical formats, an internet site was considered “comprehensive” when a clear program description accompanied resources for at least 3 ASP elements or strategies per the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America ASP guidelines [3]. Resulting data were evaluated and are presented using descriptive statistics. The UHC member list produced 407 hospitals for evaluation. Of these, 24 (6%) were found to have online ASP resources through 18 unique websites. The Midwest and South US regions each account for a third of the websites. The median hospital size with an ASP website is just over 600 beds (range, 25–1550 beds). The Ohio State University Medical Center (Wexner Medical Center; http://rx.medctr.ohiostate.edu/asp/) incorporates password restriction and The University of Chicago Medicine utilizes the social media website Facebook as a vehicle for their ASP website. A general program description and contact information are provided by 13 (72%) and 14 (78%) sites, respectively. A list of ASP members is available on 13 (72%) sites, with 15 (83%) sites disclosing both pharmacist and physician involvement. An antibiogram and external hyperlinks related to antimicrobial use are
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human urothelial cells in tissue explants from volunteers, and the analysis of shed human urothelial cells collected from the urine of women with UTI symptoms indicates the presence of intracellular E. coli [8,9]. Together, these sorts of observations suggest that intracellular UPEC reservoirs are likely more than a mousespecific laboratory phenomenon. However, Kaye and Sobel are correct in noting that the ability of UPEC to persist longterm intracellularly within the human urinary tract has not been established. Determining if intracellular UPEC reservoirs contribute to recurrent UTIs within the human population is a daunting task, plagued by issues of tissue procurement and contamination, possible reinoculation of the bladder by UPEC from niches outside of the urinary tract, and limited means to accurately detect small numbers of bacteria within a relatively enormous tissue. Ultimately, defining the relevance of intracellular UPEC reservoirs to the etiology of recurrent UTIs may only come to light with the development of approaches that can eradicate the reservoirs. We of course agree with Kaye and Sobel that it is premature to alter treatment protocols for recurrent or chronic UTIs outside of controlled clinical investigations based solely on results from mice, but we also feel that it is important to consider alternate rational explanations for recalcitrant UTIs, whether or not they gibe with the traditional view that UPEC act as strictly extracellular pathogens.
Table 1.
Websites Determined to Be Comprehensive
Institution/Hospital
URL
Barnes-Jewish Hospital
http://bjhtoolbook.wustl.edu/
Jackson Health System (Jackson Memorial Hospital) / University of Miami Health System (Sylvester Comprehensive Cancer Center)
http://ugotabug.med.miami.edu/jmh-antimicrobialstewardship-program/
Johns Hopkins Health System (The Johns Hopkins Hospital)
http://www.hopkinsmedicine.org/amp
Maine Medical Center
http://www.mainehealth.org/workfiles/mmc_em/ Adult_Antimicrobial_Formulary_Guide.pdf
New York–Presbyterian Hospital– Columbia University Medical Center
http://www.cumc.columbia.edu/dept/id/ clinical_references.html
Stanford Hospital and Clinics
http://bugsanddrugs.stanford.edu
The Cleveland Clinic Foundation
http://www.clevelandclinicmeded.com/medicalpubs/ antimicrobial-guidelines/
The Nebraska Medical Center
http://www.nebraskamed.com/careers/educationprograms/asp http://rx.osumc.edu/asp/
UCLA Health System (Ronald Reagan UCLA Medical Center) University of Kentucky Hospital
http://www.asp.mednet.ucla.edu/pages/
University of Wisconsin Hospital and Clinics
http://www.uwhealth.org/antimicrobial-stewardship/ main/36408
Wake Forest Baptist Health
http://www.wakehealth.edu/School/CAUSE/CAUSE. htm
http://www.hosp.uky.edu/pharmacy/amt/default. html
provided by 11 (61%) and 10 (56%) sites, respec-tively. Fourteen (78%) websites note formulary restriction, of which 3 do not provide a list of restricted agents. Antimicrobial dosing recommendations and guidelines or clinical decision pathways are provided by 14 (78%) and 12 (67%) sites, respectively. Four (22%) provide information as one PDF document. Thirteen (72%) websites were determined to be comprehensive (Table 1). Publicly accessible web-based resources provided by ASPs of leading US hospitals exist in limited numbers and are primarily maintained by large institutions. Institution-specific characteristics and resources vary vastly, representing opportunity for standardization and individualization. Institutional ASP websites may be a practical vehicle to provide accessible data to practitioners from numerous professions. Future research regarding the utility of these websites and initiatives to make institution-specific
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resources available on a mobile platform (eg, via apps) may be of value.
Note Potential conflicts of interest. All authors: No reported conflicts. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.
Timothy P. Gauthier,1 Evan Lantz,2 Alexander Heyliger,3 Sarah M. Francis,3 and Laura Smith2 1 Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, Fort Lauderdale; 2 Department of Pharmacy, Jackson Memorial Hospital, Miami; and 3Nova Southeastern University College of Pharmacy, Fort Lauderdale, Florida
References 1. Moodley A, Mangino JE, Goff DA. Review of infectious diseases applications for iPhone/ iPad and Android: from pocket to patient. Clin Infect Dis 2013; 57:1145–54.
CORRESPONDENCE
Correspondence: Timothy P. Gauthier, PharmD, Department of Pharmacy Practice, Nova Southeastern University College of Pharmacy, 3200 S University Drive, Fort Lauderdale, FL 33328 (
[email protected]). Clinical Infectious Diseases 2014;58(3):445–6 © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America. All rights reserved. For Permissions, please e-mail: journals.
[email protected]. DOI: 10.1093/cid/cit705
Antibiotic Prophylaxis for High-Risk Patients With Acute Q Fever: No Definitive Answers Yet TO THE EDITOR—We read with interest the article by Million et al [1]. Their study attempted to answer an important question: does chemoprophylaxis after an episode of acute Q fever decrease the risk of Q fever endocarditis in high-risk patients? Q fever endocarditis developed in all patients with significant valvulopathy and no or incomplete antibiotic prophylaxis, in contrast to none of the patients who had completed 12 months of antibiotic prophylaxis. These data are in favor of prophylaxis in high-risk patients but raise several concerns. First, because patients were recruited from a world-renowned referral center, only severe or complex acute Q fever cases may have been evaluated. Indeed, the prevalence of valvulopathies (43%) was approximately 10-fold higher than in the general French population. Q fever endocarditis was diagnosed a median of 44 days after acute Q fever, an extremely short interval compared with those in previously reported series [2, 3]. Of 4 reported definite Q fever endocarditis cases, 1 was diagnosed on the basis of positive blood polymerase chain reaction findings at day 11, which could well
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The Ohio State University Medical Center (Wexner Medical Center)
2. University HealthSystem Consortium. Available at: https://www.uhc.edu/home.htm. Accessed 10 September 2013. 3. Dellit TH, Owens RC, McGowan JE, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159–77.
