Christine A. Ruh

Factors Associated with Antibiotic Misuse in Outpatient Treatment for Upper Respiratory Tract Infections

ABSTRACT The Centers for Disease Control and Prevention has promoted the appropriate use of antibiotics since 1995 when it initiated the National Campaign for Appropriate Antibiotic Use in the Community. This study examined upper respiratory tract infections included in the campaign to determine the degree to which antibiotics were appropriately prescribed and subsequent admission rates in a veteran population. This study was a retrospective chart review conducted among outpatients with a diagnosis of a respiratory tract infection, including bronchitis, pharyngitis, sinusitis, or nonspecific upper respiratory tract infection, between January 2009 and December 2011. The study found that 595 (35.8%) patients were treated appropriately, and 1,067 (64.2%) patients received therapy considered inappropriate based on the Get Smart Campaign criteria. Overall the subsequent readmission rate was 1.5%. The majority (77.5%) of patients were prescribed an antibiotic. The most common antibiotics prescribed were azithromycin (39.0%), amoxicillin-clavulanate (13.2%), and moxifloxacin (7.5%). A multivariate regression analysis demonstrated significant predictors of appropriate treatment, including the presence of tonsillar exudates (odds ratio [OR], 0.6; confidence interval [CI], 0.3 to 0.9), fever (OR, 0.6; CI, 0.4 to 0.9), and lymphadenopathy (OR, 0.4; CI, 0.3 to 0.6), while penicillin allergy (OR, 2.9; CI, 1.7 to 4.7) and cough (OR, 1.6; CI, 1.1 to 2.2) were significant predictors for inappropriate treatment. Poor compliance with the Get Smart Campaign was found in outpatients for respiratory infections. Results from this study demonstrate the overprescribing of antibiotics, while providing a focused view of improper prescribing. This article provides evidence that current efforts are insufficient for curtailing inappropriate antibiotic use.

Impact of an Antimicrobial Stewardship Program on Patient Safety in Veterans Prescribed Vancomycin

PURPOSE This study aimed to determine the safety impact of an antimicrobial stewardship program (ASP) on vancomycin-associated nephrotoxicity and to examine risk factors contributing to the development of toxicity. METHODS This was a retrospective chart review of data from 453 veterans receiving vancomycin in the VA Western New York Healthcare System between October 2006 and July 2014. Nephrotoxicity was defined as an increase in serum creatinine of ≥ 0.5 mg/dL or by 50% of baseline for 2 consecutive days. FINDINGS Patients receiving vancomycin after the implementation of the ASP were less likely to develop nephrotoxicity (odds ratio [OR] = 2.06; 95% CI, 1.02-4.28). Nephrotoxicity occurred in 6.84% of patients from the pre-ASP cohort and in 3.75% of patients after the implementation of the ASP. Predictors of nephrotoxicity included hospital service (surgical service, OR = 2.29; 95% CI, 1.13-4.64), elevated maximum trough concentration (unit OR = 1.15; 95% CI, 1.10-1.20), and concurrent piperacillin/tazobactam therapy (OR = 3.21; 95% CI, 1.43-7.96). The number of vancomycin trough concentration measurements per patient did not vary between the pre-ASP and ASP groups. IMPLICATIONS ASPs represent an important aspect of a patient-safety initiative in order to reduce vancomycin-associated nephrotoxicity. Concurrent piperacillin/tazobactam therapy, surgical service, and elevated maximum trough concentration were risk factors for nephrotoxicity.

Outcomes and Pharmacoeconomic Analysis of a Home Intravenous Antibiotic Infusion Program in Veterans

PURPOSE The use of outpatient parenteral antibiotic therapy (OPAT) programs has become more frequent because of benefits in costs with equivalent clinical outcomes compared with inpatient care. The purpose of this study was to evaluate the outcomes of our program. A modified pharmacoeconomic analysis was performed to compare costs of our program with hospital or rehabilitation facility care. METHODS This was a retrospective chart review of 96 courses of OPAT between April 1, 2011, and July 31, 2013. Clinical failures were defined as readmission or death due to worsening infection or readmission secondary to adverse drug event (ADE) to antibiotic therapy. This does not include those patients readmitted for reasons not associated with OPAT therapy, including comorbidities or elective procedures. Baseline characteristics and program-specific data were analyzed. Statistically significant variables were built into a multivariate logistic regression model to determine predictors of failure. A pharmacoeconomic analysis was performed with the use of billing records. FINDINGS Of the total episodes evaluated, 17 (17.71%) clinically failed therapy, and 79 (82.29%) were considered a success. In the multivariate analysis, number of laboratory draws (P = 0.02) and occurrence of drug reaction were significant in the final model, P = 0.02 and P = 0.001, respectively. The presence an adverse drug reaction increases the odds of failure (OR = 10.10; 95% CI, 2.69-44.90). Compared with inpatient or rehabilitation care, the cost savings was

Impact of Antimicrobial Stewardship on Outcomes in Hospitalized Veterans With Pneumonia

6,932,552.03 or

Immunomodulatory Effects of Antimicrobial Drugs

2,649,870.68, respectively. IMPLICATIONS In our study, patients tolerated OPAT well, with a low number of failures due to ADE. The clinical outcomes and cost savings of our program indicate that OPAT can be a viable alternative to long-term inpatient antimicrobial therapy.

Male veterans with complicated urinary tract infections: Influence of a patient-centered antimicrobial stewardship program.

PURPOSE The purpose of this study was to evaluate the impact of an antimicrobial stewardship program (ASP) on outcomes for inpatients with pneumonia, including length of stay, treatment duration, and 30-day readmission rates. METHODS A retrospective chart review comparing outcomes of veterans admitted with pneumonia before (2005-2006) and after (2013-2014) implementation of an ASP was conducted; pneumonia was defined according to International Classification of Diseases, Ninth Revision (ICD-9) codes. Infectious diseases physicians and pharmacist in the ASP provided appropriate recommendations to the primary medicine teams. Bivariate analysis of baseline characteristics and comorbid conditions were performed between the time frames. Least squares regression was used to analyze length of stay, time of IV to PO conversions, and duration of antibiotics. Multivariate logistic regressions were used to determine odds of 30-day readmission and odds of Clostridium difficile infections between time periods. FINDINGS There were 86 patients in the pre-ASP period and 88 patients in the ASP period. Mean length of stay decreased from 8.1 to 6.6 days (P = 0.02), total duration of antibiotic therapy decreased from 12 to 8.5 days (P < 0.0001), and time of IV to PO antibiotic conversions decreased from 5.3 to 3.9 days (P = 0.0003), before ASP and during ASP, respectively. The odds ratio of 30-day readmission before ASP was 2.78 and 0.36 during the ASP (P = 0.05). The odds ratios of Clostridium difficile infections before ASP was 2.08 and 0.48 during the ASP (P = 0.37). IMPLICATIONS The ASP interventions were associated with shorter durations of therapy, shorter lengths of stay, and lower rates of readmission and Clostridium difficile infections within 30 days. Limitations of this study are retrospective cohort design, small study population, limited study population diversity, and non-concurrent cohort times periods.

Incidence and risk factors for healthcare utilisation among patients discharged on outpatient parenteral antimicrobial therapy

This article focuses on the immunomodulatory effects of antimicrobial drugs. Since the literature in this field is large and growing, we chose to limit the scope of our article by focusing on beneficial immunomodulatory effects of antimicrobials. In this review, we do not include idiosyncratic effects of drugs such as hemolytic anemias, drug-induced rashes, interstitial nephritis, and eosinophilia because these reactions are uncommon and unpredictable and therefore not capable of being harnessed for therapeutic effect. Therefore, our review is more focused in scope than the very comprehensive review of Labro, who included all immune-mediated effects of drugs, including adverse side effects (Labro, 2012). A drug that is an immunomodulator could affect the immune system in two ways, either by up-regulation or by down-regulation of the immune response. It is interesting that the vast majority of the articles that we found in our review focused on down-regulating or immune dampening effects of antimicrobial drugs. This seems to reflect a bias in the literature that immune responses to infections in humans are over-vigorous or overactive, and leading authors to believe that outcomes of infection would be better if one lowered the immune response. We should point out that this hypothesis has not been proven formost infectious diseases. Indeed, in some infectious diseases, such as the painful outbreaks of herpes zoster, also known as shingles, the host response to the varicella zoster virus seems to be abnormally weak or underactive, and therefore, could bemadeworse by an immune dampening drug. There aremany other examples where the host immune response seems to be too weak, not too strong, such as the response to influenza virus in elderly patients who have not received the influenza vaccine.We would like to emphasize that drugswhich can down-regulate the immune systemcan result inworse outcomes in infectious diseases rather than benefit, unless we have the sophistication to know when to use these immune down regulators and when to avoid their use. The types of pathology in infections that truly represent an overreaction to a microbial pathogen would most likely be chronic or recurrent infections, where the host immune response could actually cause tissue damage out of proportion to the microbial load. Chronic obstructive pulmonary disease, or COPD, and cystic fibrosis might be examples of this type of condition. Another example of host overreaction would be where an antigen from a noninvasive microbe is released and triggers an allergic response, for

Fluoroquinolone related neuropsychiatric events in hospitalized veterans

BACKGROUND The influence of antimicrobial stewardship programs (ASPs) on outcomes in male veterans treated for complicated urinary tract infection has not been determined. METHODS This was a retrospective cohort study encompassing the study period January 1, 2005-October 31, 2014, which was conducted at a 150-bed Veterans Affairs Healthcare System facility in Buffalo, NY. Male veterans admitted for treatment of complicated urinary tract infection were identified using ICD-9-CM codes. Outcomes before and after implementation of a patient-centered ASP, including duration of antibiotic therapy, length of hospitalization, readmission within 30 days, and Clostridium difficile infection were compared. Interventions resulting from the ASP were categorized. RESULTS Of the 1,268 patients screened, 241 met criteria for inclusion in the study (n = 118 and n = 123 in the pre-ASP and ASP group, respectively). Duration of antibiotic therapy was significantly shorter in the ASP group (10.32 days vs 11.96 days; P < .0001), as was length of hospitalization (5.76 days vs 6.76 days; P = .015). There was no difference in 30-day readmission. A total of 170 interventions were identified that resulted from the ASP (1.39 interventions per patient). CONCLUSIONS ASPs may be useful to improve clinical outcomes in men with complicated urinary tract infection. Implementation of an ASP was associated with significant decreases in duration of antibiotic therapy and length of hospitalization, without adversely affecting 30-day readmission rates.

Reply to “Minimizing Antibiotic Misuse through Evidence-Based Management of Outpatient Acute Respiratory Infections”

Outpatient parenteral antimicrobial therapy (OPAT) programmes facilitate hospital discharge, but patients remain at risk of complications and consequent healthcare utilisation (HCU). Here we elucidated the incidence of and risk factors associated with HCU in OPAT patients. This was a retrospective, single-centre, case-control study of adult patients discharged on OPAT. Cases (n = 63) and controls (n = 126) were patients that did or did not utilise the healthcare system within 60 days. Characteristics associated with HCU in bivariate analysis (P ≤ 0.2) were included in a multivariable logistic regression model. Variables were retained in the final model if they were independently (P < 0.05) associated with 60-day HCU. Among all study patients, the mean age was 55 ± 16, 65% were men, and wound infection (22%) and cellulitis (14%) were common diagnoses. The cumulative incidence of 60-day unplanned HCU was 27% with a disproportionately higher incidence in the first 30 days (21%). A statin at discharge (adjusted odds ratios (aOR) 0.23, 95% confidence intervals (CIs) 0.09-0.57), number of prior admissions in past 12 months (aOR 1.48, 95% CIs 1.05-2.10), and a sepsis diagnosis (aOR 4.62, 95% CIs 1.23-17.3) were independently associated with HCU. HCU was most commonly due to non-infection related complications (44%) and worsening primary infection (31%). There are multiple risk factors for HCU in OPAT patients, and formal OPAT clinics may help to risk stratify and target the highest risk groups.

Combination treatment with extended-infusion ceftazidime/avibactam for a KPC-3-producing Klebsiella pneumoniae bacteraemia in a kidney and pancreas transplant patient

OBJECTIVE To measure the incidence and risk factors for fluoroquinolone (ciprofloxacin, moxifloxacin, and levofloxacin)-associated psychosis or delirium in a veteran population. METHODS A retrospective study was conducted in the Western New York Veterans Affairs Health System (2005-2013). Participants were hospitalized veterans receiving a fluoroquinolone for at least 48 hours (n = 631). Cases of delirium or psychosis were defined by the Diagnostic and Statistical Manual of Mental Disorders-IV criteria, and the Naranjo scale (score ≥ 1) was used to determine the probability of the adverse drug reaction being related to fluoroquinolones. A bivariate analysis of covariates followed by a multivariate logistic regression was used to determine predisposing factors to the development of delirium/psychosis. RESULTS The mean age of the population was 71.5 years (range: 22-95). Fluoroquinolone-associated delirium/psychosis occurred in 3.7% of the inpatients studied (n = 23). The median Naranjo score was 3 indicating a possible association. Psychosis/delirium occurred in 3.6% of ciprofloxacin-treated patients (n = 14/391), 4.5% of patients-treated with moxifloxacin (n = 9/200), and 0% of those receiving levofloxacin (n = 0/40); p = 0.4. Significant risk factors for development of delirium/psychosis in patients receiving a fluoroquinolone in the multivariate logistical regression included typical antipsychotic use (OR, 5.4; 95% CI: 1.4-16.7) and age. A 10-year increase in age was associated with a 1.8-fold greater odds of a neuropsychiatric event. CONCLUSIONS Fluoroquinolones may be more commonly associated with delirium/psychosis than originally reported in this veteran population. Caution should be used when prescribing a fluoroquinolone for patients on typical antipsychotics and those of advanced age.