Christine U. Oramasionwu

Guideline-Concordant Antibiotic Use and Survival Among Patients With Community-Acquired Pneumonia Admitted to the Intensive Care Unit

OBJECTIVE This study evaluated the survival benefit of US community-acquired pneumonia (CAP) practice guidelines in the intensive care unit (ICU) setting. METHODS We conducted a retrospective cohort study of adult patients with CAP who were admitted to 5 community hospital ICUs between November 1, 1999, and April 30, 2000. The guidelines for antibiotic prescriptions were the 2007 Infectious Diseases Society of America/American Thoracic Society guidelines. Guideline-concordant antimicrobial therapy was defined as a beta-lactam plus fluoroquinolone or macrolide, antipseudomonal beta-lactam plus fluoroquinolone, or antipseudomonal beta-lactam plus aminoglycoside plus fluoroquinolone or macrolide. Patients with a documented beta-lactam allergy were considered to have received guideline-concordant therapy if they received a fluoroquinolone with or without clindamycin, or aztreonam plus fluoroquinolone with or without aminoglycoside. All other antibiotic regimens were considered to be guideline discordant. Time to clinical stability, time to oral antibiotics, length of hospital stay, and in-hospital mortality were evaluated with regression models that included the outcome as the dependent variable, guideline-concordant antibiotic therapy as the independent variable, and the Pneumonia Severity Index (PSI) score and facility as covariates. RESULTS The median age of the 129 patients included in the study was 71 years (interquartile range, 60-79 years). Sixty-two of 129 patients (48%) were male. Comorbidities included liver dysfunction (7 patients [5%]), heart failure (62 [48%]), renal dysfunction (39 [30%]), cerebrovascular disease (21 [16%]), and cancer (14 [11%]). The median (25th-75th percentile) PSI score was 119 (98-142), and overall mortality was 19% (25 patients). Patient demographics were similar between groups. Fifty-three patients (41%) received guideline-endorsed therapies. Guideline-discordant therapy was associated with an increase in inpatient mortality (25% vs 11%; odds ratio = 2.99 [95% CI, 1.08-9.54]). Receipt of guideline-concordant antibiotics was not associated with reductions in time to clinical stability, time to oral antibiotics, or length of hospital stay when patients who died were excluded from the analysis. CONCLUSION Guideline-concordant empiric antibiotic therapy was associated with improved survival among these patients with CAP who were admitted to 5 ICUs.

Emergence of community-acquired methicillin-resistant Staphylococcus aureus skin and soft tissue infections as a common cause of hospitalization in United States children

BACKGROUND Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) was first observed in pediatric patients in the late 1990s. Since then, possible risk factors for contracting CA-MRSA have been hypothesized, but supporting studies are limited. METHODS We analyzed hospital discharge records for patients with a principal International Classification of Diseases, Ninth Revision code for skin and soft tissue infections, collected from 1996 to 2006 by the United States National Center for Health Statistics. Noninstitutional, short-stay hospitals in the United States participated. The sample was limited to patients aged ≤19 years. Staphylococcus aureus and CA-MRSA were defined by International Classification of Diseases, Ninth Revision codes. Data weights were used to derive regional and national estimates. Population estimates were obtained from the US Bureau of the Census, and incidence rates were reported per 100,000 persons. Risk factors for CA-MRSA were first identified using χ(2) and χ(2) goodness-of-fit tests, then by multivariable logistic regression. RESULTS These data represent 616,375 pediatric discharges for skin and soft tissue infections from U.S. hospitals between 1996 and 2006. This represents approximately 69.9 hospitalizations for skin and soft tissue infections per 100,000 U.S. children per year. Staphylococcus aureus and CA-MRSA accounted for 19.6% and 9.6% of these cases, respectively. The rate of hospitalization for CA-MRSA skin and soft tissue infections increased dramatically over the study period; from less than one case per 100,000 in 1996 to 25.5 cases per 100,000 in 2006. Rates of CA-MRSA varied by region, with the South region having the highest rate (11.5 per 100,000 US children), followed by the West (5.2), Northeast (3.4), and Midwest (3.2). Peak CA-MRSA incidence occurred from May to December; however, the incidence in the South region was consistently higher than other regions for most months and the period of peak incidence was longer than other regions. Independent risk factors for CA-MRSA included survey year, race, geographic region, hospital size, and health insurance status (P < .0001 for all risk factors). CONCLUSIONS Pediatric hospitalizations for methicillin-susceptible S. aureus and CA-MRSA skin and soft tissue infections are on the rise. Possible risk factors for CA-MRSA infection include White race, residence in the South region of the United States, and lack of health insurance.

Racial/Ethnic and Gender Gaps in the Use of and Adherence to Evidence-Based Preventive Therapies Among Elderly Medicare Part D Beneficiaries After Acute Myocardial Infarction

Background— It is unclear whether gender and racial/ethnic gaps in the use of and patient adherence to &bgr;-blockers, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, and statins after acute myocardial infarction have persisted after establishment of the Medicare Part D prescription program. Methods and Results— This retrospective cohort study used 2007 to 2009 Medicare service claims among Medicare beneficiaries ≥65 years of age who were alive 30 days after an index acute myocardial infarction hospitalization in 2008. Multivariable logistic regression models examined racial/ethnic (white, black, Hispanic, Asian, and other) and gender differences in the use of these therapies in the 30 days after discharge and patient adherence at 12 months after discharge, adjusting for patient baseline sociodemographic and clinical characteristics. Of 85 017 individuals, 55%, 76%, and 61% used angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, &bgr;-blockers, and statins, respectively, within 30 days after discharge. No marked differences in use were found by race/ethnicity, but women were less likely to use angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and &bgr;-blockers compared with men. However, at 12 months after discharge, compared with white men, black and Hispanic women had the lowest likelihood (≈30%–36% lower; P<0.05) of being adherent, followed by white, Asian, and other women and black and Hispanic men (≈9%–27% lower; P<0.05). No significant difference was shown between Asian/other men and white men. Conclusions— Although minorities were initially no less likely to use the therapies after acute myocardial infarction discharge compared with white patients, black and Hispanic patients had significantly lower adherence over 12 months. Strategies to address gender and racial/ethnic gaps in the elderly are needed.

Rethinking adherence: a health literacy-informed model of medication self-management.

Medication adherence has received a great deal of attention over the past several decades; however, its definition and measurement remain elusive. The authors propose a new definition of medication self-management that is guided by evidence from the field of health literacy. Specifically, a new conceptual model is introduced that deconstructs the tasks associated with taking prescription drugs; including the knowledge, skills and behaviors necessary for patients to correctly take medications and sustain use over time in ambulatory care. This model is then used to review and criticize current adherence measures as well as to offer guidance to future interventions promoting medication self-management, especially among patients with low literacy skills.

Trimethoprim-Sulfamethoxazole or Clindamycin for Community-Associated MRSA (CA-MRSA) Skin Infections

Background: In the United States, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as the predominant cause of skin infections. Trimethoprim-sulfamethoxazole (TMP-SMX) and clindamycin are often used as first-line treatment options, but clinical data are lacking. Methods: We conducted a retrospective cohort study of outpatients with skin and soft tissue infections managed from July 1 to December 31, 2006. Patients younger than 18 years of age were excluded, as were those who had no clinical admission or progress notes; were hospitalized within the 90 days before admission; were hospitalized with polymicrobial, surgical site, catheter-related, or diabetic foot infections; or were discharged to places other than home. Patient demographics, comorbidities, diagnoses, cultures, prescribed antibiotics, susceptibilities, surgical procedures, and health outcomes were extracted from electronic medical records. Patients were divided in 2 cohorts for further analysis: TMP-SMX and clindamycin. The primary study outcome was composite failure defined as an additional positive MRSA culture from any site 5 to 90 days after treatment initiation or an additional intervention during a subsequent outpatient or inpatient visit. Baseline characteristics and failure rates were compared using χ2, Fishers exact, and Wilcoxon rank sum tests. Results: A total of 149 patients were included in this study. These patients had a median age of 36 years, 55% were men, 71% were Hispanic, 42% were uninsured, and 60% received an incision and drainage procedure. Patients who did not receive incision and drainage were twice as likely to experience the composite failure endpoint (57% vs 29%; P < .001). Failure rates were 25% for patients who received incision and drainage plus antibiotics compared with 60% for patients who received incision and drainage minus antibiotics (P = .03). When patients who did not receive incision and drainage were excluded, there were no significant differences between the TMP-SMX (n = 54) and clindamycin (n = 20) cohorts with respect to composite failures (26% vs 25%), microbiologic failures (13% vs 15%), additional inpatient interventions (6% vs 5%), or additional outpatient interventions (20% vs 20%). Conclusions: Our findings reinforce the belief that incision and drainage and antibiotics are critical for the management of CA-MRSA skin infections. Patients who receive TMP-SMX or clindamycin for their CA-MRSA skin infections experience similar rates of treatment failure.

HIV/AIDS Disparities: The mounting epidemic plaguing US blacks

The human immunodeficiency virus (HIV)/AIDS epidemic presents a formidable challenge for the black community. Blacks, although a small proportion of the US population, are overrepresented, not only in the number of people living with HIV, but also in the categories of new diagnoses and AIDS-related deaths. Fortunately, national initiatives are in place to slow and ultimately reverse these racial inequities. While these disparities may be widely recognized, their causes are not clearly understood. A variety of underlying issues exist for blacks in the United States that may also contribute to these growing disparities. These include transmission risk factors, socioeconomic factors, underrecognition, delayed presentation, and other comorbid conditions. We present a review of the literature regarding the potential causes of racial disparities and how they may contribute to health outcomes for blacks with HIV/AIDS in the United States. We also identify possible gaps in knowledge and offer future directions for research of HIV/AIDS racial disparities.

Black race as a predictor of poor health outcomes among a national cohort of HIV/AIDS patients admitted to US hospitals: a cohort study

BackgroundIn general, the Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) population has begun to experience the benefits of highly active antiretroviral therapy (HAART); unfortunately, these benefits have not extended equally to Blacks in the United States, possibly due to differences in patient comorbidities and demographics. These differences include rates of hepatitis B and C infection, substance use, and socioeconomic status. To investigate the impact of these factors, we compared hospital mortality and length of stay (LOS) between Blacks and Whites with HIV/AIDS while adjusting for differences in these key characteristics.MethodsThe 1996–2006 National Hospital Discharge Surveys were used to identify HIV/AIDS patients admitted to US hospitals. Survey weights were incorporated to provide national estimates. Patients < 18 years of age, those who left against medical advice, those with an unknown discharge disposition and those with a LOS < 1 day were excluded. Patients were stratified into subgroups by race (Black or White). Two multivariable logistic regression models were constructed with race as the independent variable and outcomes (mortality and LOS > 10 days) as the dependent variables. Factors that were significantly different between Blacks and Whites at baseline via bivariable statistical tests were included as covariates.ResultsIn the general US population, there are approximately 5 times fewer Blacks than Whites. In the present study, 1.5 million HIV/AIDS hospital discharges were identified and Blacks were 6 times more likely to be hospitalized than Whites. Notably, Blacks had higher rates of substance use (30% vs. 24%; P < 0.001), opportunistic infections (27% vs. 26%; P < 0.001) and cocaine use (13% vs. 5%; P < 0.001). Conversely, fewer Blacks were co-infected with hepatitis C virus (8% vs. 12%; P < 0.001). Hepatitis B virus was relatively infrequent (3% for both groups). Crude mortality rates were similar for both cohorts (5%); however, a greater proportion of Blacks had a LOS > 10 days (21% vs. 19%; P < 0.001). Black race, in the presence of comorbidities, was correlated with a higher odds of LOS > 10 days (OR, 95% CI = 1.20 [1.10–1.30]), but was not significantly correlated with a higher odds of mortality (OR, 95% CI = 1.07 [0.93–1.25]).ConclusionBlack race is a predictor of LOS > 10 days, but not mortality, among HIV/AIDS patients admitted to US hospitals. It is possible that racial disparities in hospital outcomes may be closing with time.

The Environmental and Social Influences of HIV/AIDS in Sub-Saharan Africa: A Focus on Rural Communities

The Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) pandemic has caused far-reaching effects in sub-Saharan Africa. The pandemic has effectively diminished the workforce, increased poverty rates, reduced agricultural productivity, and transformed the structure of many rural households. HIV/AIDS further strains the already fragile relationship between livelihood and the natural and social environments of these regions. Therefore, the objective of this review is to characterize the impact of HIV/AIDS on the environment and the social infrastructure of rural sub-Saharan Africa. There are many aspects of rural life that contribute to disease transmission of HIV/AIDS and that pose unique challenges to the population dynamics in sub-Saharan Africa. Widespread AIDS-related mortality has caused a decrease in population growth for many African countries. In turn, these alterations in population dynamics have resulted in a decrease in the percentage of prime-age working adults, as well as a gender disparity, whereby, females carry a growing burden of household responsibilities. There is a rising proportion of older adults, often females, who assume the role of provider and caretaker for other dependent family members. These changing dynamics have caused many to exploit their natural surroundings, adopting less sustainable land use practices and utilizing protected resources as a primary means of generating revenue.

Evaluating HIV/AIDS disparities for blacks in the United States: A review of antiretroviral and mortality studies

The purpose of this systematic review was to identify studies that evaluated HIV/AIDS disparities by examining differences in the receipt of antiretroviral therapy and differences in mortality between blacks and whites in the United States. The authors conducted 2 Web-based literature searches of the MEDLINE database for published peer reviewed scientific articles that analyzed black race as a predictor of antiretroviral therapy and mortality. Five reports met the criteria for the antiretroviral literature search, whereas seven reports met the criteria for the mortality literature search. After evaluating individual study results, it appears the evidence to identify racial differences in the receipt of antiretroviral therapy as well as the evidence to document disparities in mortality is either limited or mixed. Further research is needed to support or refute the hypothesis that there are inequalities for blacks with HIV/AIDS.

Barriers to hepatitis C antiviral therapy in HIV/HCV co-infected patients in the United States: a review.

This review synthesized the literature for barriers to HCV antiviral treatment in persons with HIV/HCV co-infection. Searches of PubMed, Embase, CINAHL, and Web of Science were conducted to identify relevant articles. Articles were excluded based on the following criteria: study conducted outside of the United States, not original research, pediatric study population, experimental study design, non-HIV or non-HCV study population, and article published in a language other than English. Sixteen studies met criteria and varied widely in terms of study setting and design. Hepatic decompensation was the most commonly documented absolute/nonmodifiable medical barrier. Substance use was widely reported as a relative/modifiable medical barrier. Patient-level barriers included nonadherence to medical care, refusal of therapy, and social circumstances. Provider-level barriers included provider inexperience with antiviral treatment and/or reluctance of providers to refer patients for treatment. There are many ongoing challenges that are unique to managing this patient population effectively. Documenting and evaluating these obstacles are critical steps to managing and caring for these individuals in the future. In order to improve uptake of HCV therapy in persons with HIV/HCV co-infection, it is essential that barriers, both new and ongoing, are addressed, otherwise, treatment is of little benefit.