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Nickel KB, Durkin MJ, Olsen MA, Sahrmann JM, Neuner E, O’Neil CA, Butler AM. Utilization of broad- versus narrow-spectrum antibiotics for the treatment of outpatient community-acquired pneumonia among adults in the United States. Pharmacoepidemiol Drug Saf 2024; 33:e5779. [PMID: 38511244 PMCID: PMC11016291 DOI: 10.1002/pds.5779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 02/22/2024] [Accepted: 03/04/2024] [Indexed: 03/22/2024]
Abstract
PURPOSE To characterize antibiotic utilization for outpatient community-acquired pneumonia (CAP) in the United States. METHODS We conducted a cohort study among adults 18-64 years diagnosed with outpatient CAP and a same-day guideline-recommended oral antibiotic fill in the MarketScan® Commercial Database (2008-2019). We excluded patients coded for chronic lung disease or immunosuppressive disease; recent hospitalization or frequent healthcare exposure (e.g., home wound care, patients with cancer); recent antibiotics; or recent infection. We characterized utilization of broad-spectrum antibiotics (respiratory fluoroquinolone, β-lactam + macrolide, β-lactam + doxycycline) versus narrow-spectrum antibiotics (macrolide, doxycycline) overall and by patient- and provider-level characteristics. Per 2007 IDSA/ATS guidelines, we stratified analyses by otherwise healthy patients and patients with comorbidities (coded for diabetes; chronic heart, liver, or renal disease; etc.). RESULTS Among 263 914 otherwise healthy CAP patients, 35% received broad-spectrum antibiotics (not recommended); among 37 161 CAP patients with comorbidities, 44% received broad-spectrum antibiotics (recommended). Ten-day antibiotic treatment durations were the most common for all antibiotic classes except macrolides. From 2008 to 2019, broad-spectrum antibiotic use substantially decreased from 45% to 19% in otherwise healthy patients (average annual percentage change [AAPC], -7.5% [95% CI -9.2%, -5.9%]), and from 55% to 29% in patients with comorbidities (AAPC, -5.8% [95% CI -8.8%, -2.6%]). In subgroup analyses, broad-spectrum antibiotic use varied by age, geographic region, provider specialty, and provider location. CONCLUSIONS Real-world use of broad-spectrum antibiotics for outpatient CAP declined over time but remained common, irrespective of comorbidity status. Prolonged duration of therapy was common. Antimicrobial stewardship is needed to aid selection according to comorbidity status and to promote shorter courses.
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Affiliation(s)
- Katelin B. Nickel
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Michael J. Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Margaret A. Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - John M. Sahrmann
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Elizabeth Neuner
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Caroline A. O’Neil
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Anne M. Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
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Jover-Sáenz A, Ramírez-Hidalgo M, Bellés Bellés A, Ribes Murillo E, Batlle Bosch M, Ribé Miró A, Mari López A, Cayado Cabanillas J, Piqué Palacín N, Garrido-Calvo S, Ortiz Valls M, Gracia Vilas MI, Gros Navés L, Javierre Caudevilla MJ, Montull Navarro L, Bañeres Argiles C, Vaqué Castilla P, Ichart Tomás JJ, Saura Codina M, Andreu Mayor E, Martorell Solé R, Vena Martínez A, Albalad Samper JM, Cano Marrón S, Soler Elcacho C, Rodríguez Garrocho A, Terrer Manrique G, Solé Curcó A, Escuin DDLR, Estadella Servalls MJ, Figueres Farreny AM, Montaña Esteban LM, Sanz Borrell L, Morales Valle A, Pallerola Planes M, Hamadi A, Pujol Aymerich F, Toribio Redondo F, Urgelés Castillón MC, Valgañon Palacios J, Olivart Parejo M, Torres-Puig-gros J. Effects of a Primary Care Antimicrobial Stewardship Program on Meticillin-Resistant Staphylococcus aureus Strains across a Region of Catalunya (Spain) over 5 Years. Antibiotics (Basel) 2024; 13:92. [PMID: 38247651 PMCID: PMC10812605 DOI: 10.3390/antibiotics13010092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/08/2024] [Accepted: 01/15/2024] [Indexed: 01/23/2024] Open
Abstract
Primary care antimicrobial stewardship program (ASP) interventions can reduce the over-prescription of unnecessary antibiotics, but the impact on the reduction in bacterial resistance is less known, and there is a lack of available data. We implemented a prolonged educational counseling ASP in a large regional outpatient setting to assess its feasibility and effectiveness. Over a 5-year post-implementation period, which was compared to a pre-intervention period, a significant reduction in antibiotic prescriptions occurred, particularly those associated with greater harmful effects and resistance selection. There was also a decrease in methicillin-resistant Staphylococcus aureus (MRSA) strains and in their co-resistance to other antibiotics, particularly those with an ecological impact.
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Affiliation(s)
- Alfredo Jover-Sáenz
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - María Ramírez-Hidalgo
- Unidad Territorial Infección Nosocomial (UTIN), Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Alba Bellés Bellés
- Sección de Microbiología, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain;
| | - Esther Ribes Murillo
- Unidad de Farmacia de Atención Primaria, Institut Català de la Salut (ICS), 25007 Lleida, Spain;
| | - Meritxell Batlle Bosch
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Anna Ribé Miró
- Equipo de Atención Priamaria (EAP) Les Borges Blanques, 25400 Lleida, Spain; (M.B.B.); (A.R.M.)
| | - Alba Mari López
- EAP Pla d’Urgell, 25001 Lleida, Spain; (A.M.L.); (J.C.C.); (N.P.P.)
| | | | | | | | | | | | | | | | | | | | | | - José Javier Ichart Tomás
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | - Mireia Saura Codina
- Servicio de Urgencias, Hospital Universitari Arnau de Vilanova de Lleida (HUAV), 25198 Lleida, Spain; (J.J.I.T.); (M.S.C.)
| | | | | | - Ana Vena Martínez
- Servei de Geriatria, Hospital Universitari Santa Maria, 25198 Lleida, Spain;
| | | | - Susana Cano Marrón
- EAP Onze de Setembre, 25005 Lleida, Spain; (S.C.M.); (C.S.E.); (A.R.G.); (G.T.M.)
| | | | | | | | | | | | | | | | | | | | | | | | - Aly Hamadi
- EAP Balaguer, 25600 Lleida, Spain; (M.P.P.); (A.H.)
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Okihata R, Michi Y, Sunakawa M, Tagashira Y. Pharmacist-led multi-faceted intervention in an antimicrobial stewardship programme at a dental university hospital in Japan. J Hosp Infect 2023; 136:30-37. [PMID: 37088217 DOI: 10.1016/j.jhin.2023.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND Antimicrobials are commonly prescribed in dentistry. However, inappropriate antimicrobial prescriptions are common in this field. Optimizing antimicrobial prescriptions in dentistry requires an effective strategy for modifying prescribing behaviour. AIM To assess the efficacy of pharmacist-led multi-faceted intervention for the proportion of monthly antimicrobial prescriptions in each drug group per 100 oral antimicrobial prescriptions. METHODS A before-after trial was performed at a university hospital outpatient dental clinic. A pharmacist-led, multi-faceted intervention, including immediate and direct feedback to the prescribers, an explanation of the rules of antimicrobial prescriptions for patients with penicillin allergy, tutorials for dentistry students, and a review of hospital-approved antimicrobials, was implemented from April 2017 to March 2022. Antimicrobials were classified into eight groups, namely, penicillins, first- and second-generation cephalosporins, third-generation cephalosporins, fluoroquinolones, macrolides, clindamycin, carbapenem, and others. FINDINGS In total, there were 2,643,988 visits to the outpatient dental clinic during the study period. The monthly mean proportion of prescriptions for penicillins increased from 45.6 to 84.1 per 100 oral antimicrobial prescriptions (P<0.001) while that of third-generation cephalosporins decreased from 43.0 to 7.3 (P<0.001) from the pre-intervention to the intervention period. Moreover, the monthly mean proportion of fluoroquinolones, macrolides, and carbapenems decreased from 11.2 to 7.44 (P<0.001). CONCLUSION The intervention modified dentists' antimicrobial prescribing behaviours, leading to an immediate increase in the number of monthly prescriptions for penicillins and a simultaneous decrease in the number of monthly prescriptions for third-generation cephalosporins and other broad-spectrum, oral antimicrobials.
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Affiliation(s)
- R Okihata
- Department of Pharmacy, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - Y Michi
- Department of Oral and Maxillofacial Surgical Oncology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan; Department of Infection Prevention and Control, Tokyo Medical and Dental University Hospital, Tokyo, Japan
| | - M Sunakawa
- Faculty of Dentistry, Tokyo Medical and Dental University, Tokyo, Japan
| | - Y Tagashira
- Department of Infection Prevention and Control, Tokyo Medical and Dental University Hospital, Tokyo, Japan; Department of Infectious Diseases, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan.
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Butler AM, Brown DS, Newland JG, Nickel KB, Sahrmann JM, O’Neil CA, Olsen MA, Zetts RM, Hyun DY, Durkin MJ. Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections. Clin Infect Dis 2023; 76:986-995. [PMID: 36350187 PMCID: PMC10226742 DOI: 10.1093/cid/ciac879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 10/28/2022] [Accepted: 11/03/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections. METHODS We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type. RESULTS Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections. CONCLUSIONS Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.
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Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Derek S Brown
- Brown School, Washington University, St. Louis, Missouri, USA
| | - Jason G Newland
- Department of Pediatrics, Washington University School of Medicine, St. Louis, St. Louis, Missouri, USA
| | - Katelin B Nickel
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - John M Sahrmann
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Caroline A O’Neil
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
- Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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Akiyama Y, Norimatsu Y, Ohno Y. Prophylactic antimicrobials may not be needed to prevent surgical site infection after skin biopsy: a retrospective study. Antimicrob Resist Infect Control 2022; 11:35. [PMID: 35172906 PMCID: PMC8848973 DOI: 10.1186/s13756-022-01077-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 02/06/2022] [Indexed: 11/12/2022] Open
Abstract
Background Two types of skin biopsies are routinely performed in dermatology: excisional and punch biopsies. A punch biopsy is a relatively low-risk procedure for surgical site infections (SSIs) because of the shallow wound depth and short operative time. In Japan, prophylactic antimicrobial agents are often used after skin biopsies due to lack of consensus, and there is no mention of antimicrobial use after skin biopsies in Japanese guidelines. In this study, we investigated whether prophylactic antibiotic use after punch biopsies reduces the risk of SSI development. Methods Cases of punch biopsy performed in our dermatology department during a one-year period from April 2018 to March 2019 were included retrospectively. The cases were divided into a group with and another without prophylactic antimicrobial use after biopsy. Results A total of 75 cases of punch skin biopsy were reviewed. There were no cases of wound infection after punch biopsy in any of the groups. The number of years of experience of the physicians in the group that used antimicrobials was significantly higher than that in the group that did not use antimicrobials (P < 0.0001). Conclusions Our result suggests that the incidence of SSI in punch biopsies without prophylaxis seems to be low. However, further research is needed due to the small number of cases in this study.
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Turk K, Jacobson Vann J, Oppewal S. Antibiotic prescribing patterns and guideline-concordant management of acute respiratory tract infections in virtual urgent care settings. J Am Assoc Nurse Pract 2022; 34:813-824. [PMID: 35472013 DOI: 10.1097/jxx.0000000000000705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/02/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Antibiotic overprescribing for acute respiratory tract infections (ARTIs) commonly occurs and can lead to higher medical costs, antibiotic resistance, and health complications. Inappropriate prescribing of antibiotics for ARTIs has been shown to occur more frequently in urgent care than other outpatient settings. It is not clear whether antibiotic overprescribing varies between virtual and in-person urgent care. OBJECTIVES Summarize published primary scientific literature on antibiotic prescribing patterns for ARTIs among adults in virtual urgent care settings. DATA SOURCES We conducted a systematic review to compare antibiotic prescribing for ARTIs between virtual and in-person urgent care. Our review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist. We assessed risk of bias using the Risk of Bias in Non-randomized Studies-of Interventions (ROBINS-I) assessment tool. We summarized study results from seven included retrospective cohort studies. CONCLUSIONS Antibiotic prescribing frequency may be similar between virtual urgent care and in-person care for adult patients treated for ARTIs. However, variability existed in intervention characteristics, settings, and outcome measures. Additional studies are needed to better understand the conditions in which virtual care may be most effective. IMPLICATIONS FOR PRACTICE Evidence suggests that giving providers direct access to evidence-based guidelines and electronic health records within the virtual visit may support diagnosis and management. Furthermore, practices that use telemedicine platforms for virtual urgent care visits should consider how to potentially improve diagnosis and management of conditions through the use of home-based point-of-care testing or accessory "e-tools."
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Butler AM, Brown DS, Durkin MJ, Sahrmann JM, Nickel KB, O’Neil CA, Olsen MA, Hyun DY, Zetts RM, Newland JG. Association of Inappropriate Outpatient Pediatric Antibiotic Prescriptions With Adverse Drug Events and Health Care Expenditures. JAMA Netw Open 2022; 5:e2214153. [PMID: 35616940 PMCID: PMC9136626 DOI: 10.1001/jamanetworkopen.2022.14153] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Nonguideline antibiotic prescribing for the treatment of pediatric infections is common, but the consequences of inappropriate antibiotics are not well described. OBJECTIVE To evaluate the comparative safety and health care expenditures of inappropriate vs appropriate oral antibiotic prescriptions for common outpatient pediatric infections. DESIGN, SETTING, AND PARTICIPANTS This cohort study included children aged 6 months to 17 years diagnosed with a bacterial infection (suppurative otitis media [OM], pharyngitis, sinusitis) or viral infection (influenza, viral upper respiratory infection [URI], bronchiolitis, bronchitis, nonsuppurative OM) as an outpatient from April 1, 2016, to September 30, 2018, in the IBM MarketScan Commercial Database. Data were analyzed from August to November 2021. EXPOSURES Inappropriate (ie, non-guideline-recommended) vs appropriate (ie, guideline-recommended) oral antibiotic agents dispensed from an outpatient pharmacy on the date of infection. MAIN OUTCOMES AND MEASURES Propensity score-weighted Cox proportional hazards models were used to estimate hazards ratios (HRs) and 95% CIs for the association between inappropriate antibiotic prescriptions and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable health care expenditures by infection type. National-level annual attributable expenditures were calculated by scaling attributable expenditures in the study cohort to the national employer-sponsored insurance population. RESULTS The cohort included 2 804 245 eligible children (52% male; median [IQR] age, 8 [4-12] years). Overall, 31% to 36% received inappropriate antibiotics for bacterial infections and 4% to 70% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and severe allergic reaction among children treated with a nonrecommended antibiotic agent for a bacterial infection (among patients with suppurative OM, C. difficile infection: HR, 6.23; 95% CI, 2.24-17.32; allergic reaction: HR, 4.14; 95% CI, 2.48-6.92). Thirty-day attributable health care expenditures were generally higher among children who received inappropriate antibiotics, ranging from $21 to $56 for bacterial infections and from -$96 to $97 for viral infections. National annual attributable expenditure estimates were highest for suppurative OM ($25.3 million), pharyngitis ($21.3 million), and viral URI ($19.1 million). CONCLUSIONS AND RELEVANCE In this cohort study of children with common infections treated in an outpatient setting, inappropriate antibiotic prescriptions were common and associated with increased risks of adverse drug events and higher attributable health care expenditures. These findings highlight the individual- and national-level consequences of inappropriate antibiotic prescribing and further support implementation of outpatient antibiotic stewardship programs.
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Affiliation(s)
- Anne M. Butler
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | - Michael J. Durkin
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - John M. Sahrmann
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Katelin B. Nickel
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Caroline A. O’Neil
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Margaret A. Olsen
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St Louis, Missouri
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | | | | | - Jason G. Newland
- Department of Pediatrics, Washington University School of Medicine, St Louis, Missouri
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Poole NM, Frost H. Targets and Methods to Improve Outpatient Antibiotic Prescribing for Pediatric Patients. Infect Dis Clin North Am 2022; 36:187-202. [DOI: 10.1016/j.idc.2021.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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9
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Forrester JD, Cao S, Schaps D, Liou R, Patil A, Stave C, Sokolow SH, Leo GD. Influence of Socioeconomic and Environmental Determinants of Health on Human Infection and Colonization with Antibiotic-Resistant and Antibiotic-Associated Pathogens: A Scoping Review. Surg Infect (Larchmt) 2022; 23:209-225. [DOI: 10.1089/sur.2021.348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Joseph D. Forrester
- Division of General Surgery, Department of Surgery, Stanford University, Stanford, California, USA
| | - Siqi Cao
- School of Medicine, Stanford University, Stanford, California, USA
| | - Diego Schaps
- School of Medicine, Duke University, Durham, North Carolina, USA
| | - Raymond Liou
- School of Medicine, Stanford University, Stanford, California, USA
| | | | - Christopher Stave
- School of Medicine, Stanford University, Stanford, California, USA
- Lane Medical Library, Stanford University, Stanford, California, USA
| | - Susanne H. Sokolow
- Woods Institute for the Environment, Stanford University, Stanford, California, USA
- Marine Science Institute, University of California Santa Barbara, Santa Barbara, California, USA
| | - Giulio De Leo
- Woods Institute for the Environment, Stanford University, Stanford, California, USA
- Hopkins Marine Station, Stanford University, Stanford, California, USA
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Bao H, Dubrovskaya Y, Jen SP, Decano A, Ahmed N, Pham VP, Papadopoulos J, Siegfried J. Novel Multidisciplinary Approach for Outpatient Antimicrobial Stewardship Using an Emergency Department Follow-Up Program. J Pharm Pract 2021; 36:329-335. [PMID: 34592864 DOI: 10.1177/08971900211048311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: Outpatient antimicrobial stewardship programs (ASPs) are becoming increasingly prevalent in healthcare. Many programs have demonstrated the effectiveness of pharmacist-driven outpatient consultations or follow-up programs to ensure appropriate antimicrobial prescribing. However, there is a paucity of literature describing multidisciplinary approaches in large healthcare systems for patients discharged from the emergency department (ED). The objective of this study was to describe the feasibility and impact of a combined effort between ASP pharmacotherapy specialists and nurse practitioners (NPs) in managing an ED follow-up center. Methods: A retrospective analysis was conducted for patients discharged from the ED between January 2018 and June 2019. Patients were identified for inclusion based on documentation by ASP pharmacotherapy specialists in the electronic health record for patient-specific inquiries from ED follow-up center NPs. The primary outcome of this study was to describe the number and types of interventions made by ASP pharmacotherapy specialists. Results: A total of 1088 patients were included in the study, for 1114 documented ASP calls. The urinary tract was the most common source of positive culture (79%), and third-generation cephalosporins were the most frequent antibiotic associated with calls (20%). Out of total calls, 60% lead to ASP interventions. Among total calls, the most frequent interventions were to correct drug-bug mismatches (20%), initiate new therapy (10%), and discontinue therapy (7%). Conclusion: This report describes a novel initiative that combines the efforts of ED NPs and ASP pharmacotherapy specialists in managing an ED follow-up center at a large healthcare system.
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Affiliation(s)
- Hongkai Bao
- Department of Pharmacy, Montefiore Medical Center, the Bronx, NY, USA
| | - Yanina Dubrovskaya
- Department of Pharmacy, 12297NYU Langone Health, New York, NY, USA.,Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Shin-Pung Jen
- Department of Pharmacy, Newark Beth Israel Medical Center, Newark, NJ, USA
| | - Arnold Decano
- Department of Pharmacy, NYU Langone Hospital Brooklyn, Brooklyn, NY, USA
| | - Nabeela Ahmed
- Department of Pharmacy, NYU Langone Hospital Brooklyn, Brooklyn, NY, USA
| | - Vinh P Pham
- Department of Medicine, New York University School of Medicine, New York, NY, USA.,Division of Infectious Diseases and Immunology, Department of Medicine, NYU Langone Health, New York, NY, USA
| | - John Papadopoulos
- Department of Pharmacy, 12297NYU Langone Health, New York, NY, USA.,Department of Medicine, New York University School of Medicine, New York, NY, USA
| | - Justin Siegfried
- Department of Pharmacy, 12297NYU Langone Health, New York, NY, USA
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Attitudes on Prophylactic Antibiotic Use in Dermatologic Surgery: A Survey Study of American College of Mohs Surgery Members. Dermatol Surg 2021; 47:339-342. [PMID: 32897951 DOI: 10.1097/dss.0000000000002676] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antibiotic prescriptions associated with dermatologic surgical visits are increasing and prescribing practices vary among surgeons. OBJECTIVE To describe dermatologic surgeons' attitudes and practices regarding prophylactic antibiotic use for surgical site infection (SSI), to compare current prescribing practices to those of a 2012 survey, and to determine surgeons' interest in clinical trial data on the utility of prophylactic antibiotics. MATERIALS AND METHODS This was a cross-sectional online survey of the American College of Mohs Surgery (ACMS) members. Survey items were adapted from a 2012 survey of ACMS members. RESULTS The survey was initiated by 101 ACMS members. 75.25% (76/101) of surgeons reported routinely prescribing prophylactic antibiotics to reduce SSI risk. The use of prophylactic antibiotics varied with clinical scenario. Most providers (84.21%, 64/76) prescribe postoperative antibiotics, with an average course of 6.56 days. 40.21% (39/97) of respondents were uncertain if prophylaxis prevents SSI, and up to 90.63% (87/96) indicated interest in clinical trial data evaluating the efficacy of oral antibiotics for SSI prevention. CONCLUSION Dermatologic surgeons continue to report varied attitudes and practices for SSI prophylaxis. Evidence from clinical trials is desired by surgeons to guide clinical practice.
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Tydeman F, Craine N, Kavanagh K, Adams H, Reynolds R, McClure V, Hughes H, Hickman M, Robertson C. Incidence of Clostridioides difficile infection (CDI) related to antibiotic prescribing by GP surgeries in Wales. J Antimicrob Chemother 2021; 76:2437-2445. [PMID: 34151964 PMCID: PMC8361358 DOI: 10.1093/jac/dkab204] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 05/24/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is a healthcare-acquired infection (HAI) causing significant morbidity and mortality. Welsh CDI rates are high in comparison with those in England and Scotland. OBJECTIVES This retrospective ecological study used aggregated disease surveillance data to understand the impact of total and high-risk Welsh GP antibiotic prescribing on total and stratified inpatient/non-inpatient CDI incidence. METHODS All cases of confirmed CDI, during the financial years 2014-15 to 2017-18, were linked to aggregated rates of antibiotic prescribing in their GP surgery and classified as 'inpatient', 'non-inpatient' or 'unknown' by Public Health Wales. Multivariable negative-binomial regression models, comparing CDI incidence with antibiotic prescribing rates, were adjusted for potential confounders: location; age; social deprivation; comorbidities (estimated from prevalence of key health indicators) and proton pump inhibitor (PPI) prescription rates. RESULTS There were 4613 confirmed CDI cases, with an incidence (95% CI) of 1.44 (1.40-1.48) per 1000 registered patients. Unadjusted analysis showed that an increased risk of total CDI incidence was associated with higher total antibiotic prescribing [relative risk (RR) (95% CI) = 1.338 (1.170-1.529) per 1000 items per 1000 specific therapeutic group age-sex related GP prescribing units (STAR-PU)] and that high-risk antibiotic classes were positively associated with total CDI incidence. Location, age ≥65 years and diabetes were associated with increased risk of CDI. After adjusting for confounders, prescribing of clindamycin showed a positive association with total CDI incidence [RR (95% CI) = 1.079 (1.001-1.162) log items per 1000 registered patients]. CONCLUSIONS An increased risk of CDI is demonstrated at a primary care practice population level, reflecting their antibiotic prescribing rates, particularly clindamycin, and population demographics.
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Affiliation(s)
- Florence Tydeman
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, Scotland
- Corresponding author. E-mail:
| | - Noel Craine
- CDSC, Public Health Wales, Ysbyty Gwynedd, Bangor LL57 2PW, Wales
| | - Kimberley Kavanagh
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, Scotland
| | - Helen Adams
- Betsi Cadwaladr University Health Board, Ysbyty Gwynedd, Bangor LL57 2PW, Wales
| | - Rosy Reynolds
- Population Health Sciences, Bristol Medical School, University of Bristol BS8 2PS, England
| | - Victoria McClure
- CDSC, Public Health Wales, Ysbyty Gwynedd, Bangor LL57 2PW, Wales
| | - Harriet Hughes
- Public Health Wales, Microbiology, University Hospital of Wales, Cardiff CF14 4XW, Wales
| | - Matt Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol BS8 2PS, England
| | - Chris Robertson
- Department of Mathematics and Statistics, University of Strathclyde, Glasgow G1 1XH, Scotland
- Health Protection Scotland, Glasgow G2 6QE, Scotland
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Okeah BO, Morrison V, Huws JC. Antimicrobial stewardship and infection prevention interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae infections: a scoping review. BMJ Open 2021; 11:e051983. [PMID: 34348956 PMCID: PMC8340296 DOI: 10.1136/bmjopen-2021-051983] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 07/23/2021] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES This study assessed antimicrobial stewardship (AMS) and infection prevention (IP) interventions targeting healthcare-associated Clostridioides difficile and carbapenem-resistant Klebsiella pneumoniae (CRKP) infections, their key outcomes and the application of behaviour change principles in these interventions. DESIGN This scoping review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis Extension for Scoping Reviews (PRISMA-ScR) guidelines while focusing on acute healthcare settings in both low-to-middle income and high-income countries. DATA SOURCES The databases searched were MEDLINE, PubMed, Web of Science and CINAHL between 22 April 2020 and 30 September 2020. ELIGIBILITY The review included peer-reviewed articles published in English language between 2010 and 2019. Studies that focussed on IP and/or AMS interventions primarily targeting C. difficile or CRKP were included. Studies that assessed effectiveness of diagnostic devices or treatment options were excluded from this review. DATA EXTRACTION AND SYNTHESIS An abstraction sheet calibrated for this study was used to extract data on the main study characteristics including the population, intervention and outcomes of interest (antimicrobial use, compliance with IP interventions and risk for C. difficile and CRKP). A narrative synthesis of the results is provided. RESULTS The review included 34 studies. Analysis indicates that interventions targeting C. difficile and CRKP include Education, Surveillance/Screening, Consultations, Audits, Policies and Protocols, Environmental measures, Bundles, Isolation as well as Notifications or alerts (represented using the ESCAPE-BIN acronym). The identified outcomes include antimicrobial use, resistance rates, risk reduction, adherence to contact precautions, hospital stay and time savings. AMS and IP interventions tend to be more adhoc with limited application of behaviour change principles. CONCLUSION This scoping review identified the AMS and IP interventions targeting C. difficile and CRKP in healthcare settings and described their key outcomes. The application of behaviour change principles in AMS and IP interventions appears to be limited.
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Affiliation(s)
| | | | - Jaci C Huws
- School of Medical & Health Sciences, Bangor University, Bangor, UK
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14
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Knobloch MJ, Musuuza J, Baubie K, Saban KL, Suda KJ, Safdar N. Nurse practitioners as antibiotic stewards: Examining prescribing patterns and perceptions. Am J Infect Control 2021; 49:1052-1057. [PMID: 33524451 DOI: 10.1016/j.ajic.2021.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/19/2021] [Accepted: 01/20/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND Advanced practice providers in the outpatient setting play a key role in antibiotic stewardship, yet little is known about how to engage these providers in stewardship activities and what factors influence their antibiotic prescribing practices. METHODS We used mixed methods to obtain data on practices and perceptions related to antibiotic prescribing by nurse practitioners (NP) and Veteran patients. We interviewed NPs working in the outpatient setting at one Veterans Affairs facility and conducted focus groups with Veterans. Emerging themes were mapped to the Systems Engineering Initiative for Patient Safety framework. We examined NP antibiotic prescribing data from 2017 to 2019. RESULTS We interviewed NPs and conducted Veteran focus groups. Nurse practitioners reported satisfaction with resources, including ready access to pharmacists and infectious disease specialists. Building patient trust was reported as essential to prescribing confidence level. Veterans indicated the need to better understand differences between viral and bacterial infections. NP prescribing patterns revealed a decline in antibiotics prescribed for upper respiratory illnesses over a 3-year period. CONCLUSION Outpatient NPs focus on educating the patient while balancing organizational access challenges. Further research is needed to determine how to include both NPs and patients when implementing outpatient antibiotic stewardship strategies. Further research is also needed to understand factors associated with the decline in nurse practitioner antibiotic prescribing observed in this study.
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Rolf von den Baumen T, Crosby M, Tadrous M, Schwartz KL, Gomes T. Measuring the impacts of the Using Antibiotics Wisely campaign on Canadian community utilization of oral antibiotics for respiratory tract infections: a time-series analysis from 2015 to 2019. J Antimicrob Chemother 2021; 76:2472-2478. [PMID: 34223899 DOI: 10.1093/jac/dkab205] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/24/2021] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND On 1 November 2018, Choosing Wisely Canada launched their Using Antibiotics Wisely primary care campaign, which aimed to reduce unnecessary antibiotic prescriptions for respiratory tract infections (RTIs) through educational tools for patients and providers. OBJECTIVES We explored the impact of this campaign on antibiotic utilization in Canada. METHODS We conducted a population-based study in Canada between January 2015 and December 2019. We used interventional autoregressive integrated moving average models to study the impact of the Using Antibiotics Wisely campaign on the prescribing rate (prescriptions per 1000 population) of RTI-indicated antibiotics. We analysed prescription rates overall and stratified by age group, drug class and province, in each month over the study period. RESULTS There was a 1.5% reduction in the annual prescribing rate of RTI-indicated antibiotics over the study period, which was generally consistent across age groups and provinces. Following the 2018 Using Antibiotics Wisely clinician toolkit release, we observed no significant change in RTI-indicated antibiotic prescribing rates nationally (P = 0.13). This was consistent by age group (children, P = 0.91; adults, P = 0.58; and older adults, P = 0.67) and drug class (narrow-spectrum penicillins, P = 0.88; macrolides, P = 0.85; broad-spectrum penicillins, P = 0.60; cephalosporins, P = 0.45; tetracyclines, P = 0.55; and fluoroquinolones, P = 0.98). In our secondary analysis of prescription rates in provinces that self-identified as prioritizing Using Antibiotics Wisely, we observed no significant change following the launch of the campaign. CONCLUSIONS The introduction of the Using Antibiotics Wisely campaign in Canada has not caused a significant change in short-term antibiotic prescribing patterns. Community antibiotic stewardship campaigns that include components beyond education may be more impactful.
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Affiliation(s)
| | - Michael Crosby
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada
| | - Mina Tadrous
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Women's College Hospital Research Institute, Toronto, Ontario, Canada
| | - Kevin L Schwartz
- Public Health Ontario, Toronto, Ontario, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.,Unity Health Toronto, Toronto, Ontario, Canada
| | - Tara Gomes
- Leslie Dan Faculty of Pharmacy at the University of Toronto, Toronto, Ontario, Canada.,Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.,Institute of Health Policy, Management and Evaluation at the University of Toronto, Toronto, Ontario, Canada
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16
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Impact of Antecedent Antibiotic Usage on Community-associated Clostridioides difficile Infection in Pediatrics. Pediatr Infect Dis J 2021; 40:426-428. [PMID: 33591073 DOI: 10.1097/inf.0000000000002991] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Children exposed to antibiotics develop community-associated Clostridioides difficile infections in the 12 weeks following exposure. This secondary analysis was a retrospective review of children with filled prescriptions for commonly prescribed antibiotics between January 1, 2012, and December 31, 2016. Compared with amoxicillin, incident rates of community-associated Clostridioides difficile infections were highest following clindamycin, cephalosporins, and amoxicillin-clavulanate.
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Concordance of antibiotic prescribing with the American Dental Association acute oral infection guidelines within Veterans' Affairs (VA) dentistry. Infect Control Hosp Epidemiol 2021; 42:1422-1430. [PMID: 33650474 DOI: 10.1017/ice.2021.16] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVE United States dentists prescribe 10% of all outpatient antibiotics. Assessing appropriateness of antibiotic prescribing has been challenging due to a lack of guidelines for oral infections. In 2019, the American Dental Association (ADA) published clinical practice guidelines (CPG) on the management of acute oral infections. Our objective was to describe baseline national antibiotic prescribing for acute oral infections prior to the release of the ADA CPG and to identify patient-level variables associated with an antibiotic prescription. DESIGN Cross-sectional analysis. METHODS We performed an analysis of national VA data from January 1, 2017, to December 31, 2017. We identified cases of acute oral infections using International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Antibiotics prescribed by a dentist within ±7 days of a visit were included. Multivariable logistic regression identified patient-level variables associated with an antibiotic prescription. RESULTS Of the 470,039 VA dental visits with oral infections coded, 12% of patient visits with irreversible pulpitis, 17% with apical periodontitis, and 28% with acute apical abscess received antibiotics. Although the median days' supply was 7, prolonged use of antibiotics was frequent (≥8 days, 42%-49%). Patients with high-risk cardiac conditions, prosthetic joints, and endodontic, implant, and oral and maxillofacial surgery dental procedures were more likely to receive antibiotics. CONCLUSIONS Most treatments of irreversible pulpitis and apical periodontitis cases were concordant with new ADA guidelines. However, in cases where antibiotics were prescribed, prolonged antibiotic courses >7 days were frequent. These findings demonstrate opportunities for the new ADA guidelines to standardize and improve dental prescribing practices.
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18
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Multifaceted intervention for improving antimicrobial prescription at discharge in the emergency department. Infect Control Hosp Epidemiol 2021; 43:88-91. [PMID: 33541448 DOI: 10.1017/ice.2020.1436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The frequent prescription of antimicrobials, such as at discharge from the emergency department, calls for optimizing this practice through modifying physicians' prescribing behavior. A 1-year, multifaceted intervention implemented in an emergency department decreased the mean monthly antimicrobial prescription rate at discharge and increased the proportion of appropriate prescriptions.
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Golubovska I, Vigante D, Malzubris M, Raga L, Isajevs S, Miscuks A. Severe Clostridium difficile infection with extremely high leucocytosis complicated by a concomitant bloodstream infection caused by Klebsiella pneumoniae after osteomyelitis surgery: A case report. Int J Surg Case Rep 2020; 78:155-158. [PMID: 33352444 PMCID: PMC7753219 DOI: 10.1016/j.ijscr.2020.12.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 12/03/2020] [Accepted: 12/05/2020] [Indexed: 11/26/2022] Open
Abstract
Exposure to antibiotics after surgery increase risk of Cl. difficile infection. Sudden high leucocytosis may be sign of poor outcome in Cl. difficile case. Oral Vancomycin could be responsible for the growth of bloodstream Kl. pneumonia.
Introduction Clostridium difficile is one of the most common healthcare-associated infections. Pseudomembranous colitis is a serious complication of Clostridium difficile infection (CDI) after septic surgery and antibacterial therapy. A sudden white blood cell (WBC) count increase and extremely high leucocytosis may be a predictor of a poor outcome. Presentation of case A 77 years old male was hospitalised because of lower leg osteomyelitis and was operated. He received antibacterial treatment with Cefazolin for three days and then developed a high WBC count. The course of the disease was fulminant, with a rapid increase in the WBC count up to 132,000/mm3 and a septic shock, and required cardiovascular and ventilatory support. The patient was started on intravenous Metronidazole (500 mg every eight hours) and oral Vancomycin (500 mg every six hours). The patient’s condition gradually improved over a period of six days. Then a hyperthermia above 39 degrees Celsius, hypotension and painful abdominal bloating developed, and the WBC count peaked to 186,000/mm3. The blood cultures were positive for Klebsiella pneumoniae. The patient died. Discussion In our case, we describe a community-onset, healthcare-facility-associated, severe CDI complicated by a blood stream infection. The administration of oral Vancomycin, which is highly active against the intestinal flora, could have been responsible for the persistence and overgrowth of Klebsiella pneumoniae. Conclusions Severe CDIs after orthopaedic surgery and antibacterial treatment complicated by the development of nosocomial infection significantly worsen the prognosis of the disease. Careful consideration of antibacterial therapy and early symptom recognition may help prevent catastrophic events.
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Affiliation(s)
- Iveta Golubovska
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia.
| | - Dace Vigante
- Department of Joint and Bone Infections, Hospital of Traumatology and Orthopedics, Riga, Latvia
| | - Martins Malzubris
- Department of Joint and Bone Infections, Hospital of Traumatology and Orthopedics, Riga, Latvia
| | - Luize Raga
- Department of Joint and Bone Infections, Hospital of Traumatology and Orthopedics, Riga, Latvia
| | - Sergejs Isajevs
- Joint Laboratory for Microbiology and Pathohistology, Hospital of Traumatology and Orthopedics, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
| | - Aleksejs Miscuks
- Department of Anesthesiology, Hospital of Traumatology and Orthopedics, Riga, Latvia; Faculty of Medicine, University of Latvia, Riga, Latvia
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20
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Implementing Antibiotic Stewardship in a Network of Urgent Care Centers. Jt Comm J Qual Patient Saf 2020; 46:682-690. [DOI: 10.1016/j.jcjq.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 08/28/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
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21
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Clostridioides difficile infection and antibiotic prescription rates in the community: Explaining the gender gap. Infect Control Hosp Epidemiol 2020; 42:622-624. [PMID: 33239121 DOI: 10.1017/ice.2020.1268] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
In this cross-sectional population-based study, women had significantly higher crude incidence rates of both community-associated Clostridioides difficile infection (CA-CDI) and ambulatory antibiotic prescriptions compared to men in South Carolina in 2015. After adjustments for antibiotic prescription rates, there was no difference in the incidence rates of CA-CDI between the genders.
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22
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Spicer JO, Roberts RM, Hicks LA. Perceptions of the Benefits and Risks of Antibiotics Among Adult Patients and Parents With High Antibiotic Utilization. Open Forum Infect Dis 2020; 7:ofaa544. [PMID: 33335939 PMCID: PMC7731524 DOI: 10.1093/ofid/ofaa544] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 11/02/2020] [Indexed: 01/21/2023] Open
Abstract
Background Inappropriate antibiotic use is common. Understanding how patients view antibiotic risks and/or benefits could inform development of patient education materials and clinician communication strategies. We explored current knowledge, attitudes, and behaviors related to antibiotics among populations with high antibiotic use. Methods We conducted 12 focus groups with adult patients and parents across the United States by telephone in March 2017. Purposive sampling was used to identify participants with high antibiotic use. We transcribed the discussions verbatim and performed thematic analysis. Results We identified 4 major themes. First, participants expressed uncertainty regarding which clinical syndromes required antibiotics, and emotion often influenced their desire for antibiotics. Second, they had a limited understanding of antibiotic risks. Antibiotic resistance was viewed as the primary risk but was seen as a “distant, future” issue, whereas immediate adverse events, such as side effects, were minimized; however, patients expressed concern when told about the risk of serious adverse events. Third, they prioritized antibiotic benefits over risks in their decision-making, both due to an inaccurate estimation of antibiotic risks and/or benefits and a tendency to prioritize instant gratification. Fourth, most participants were willing to defer to their clinicians’ decisions about antibiotics, especially if their clinician provided symptomatic treatment and anticipatory guidance. Conclusions Patients have a limited understanding of antibiotic risks, potentially explaining why they are willing to try antibiotics even if it is unclear antibiotics will help. Educating patients on the potential antibiotic risks versus benefits, rather than just antibiotic resistance, may have a bigger impact on their decision-making.
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Affiliation(s)
- Jennifer O Spicer
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Rebecca M Roberts
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Impact of California's mandate for antimicrobial stewardship programs on rates of methicillin-resistant Staphylococcus aureus and Clostridioides difficile infection in acute-care hospitals. Infect Control Hosp Epidemiol 2020; 42:298-304. [PMID: 32998788 DOI: 10.1017/ice.2020.446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE To estimate the impact of California's antimicrobial stewardship program (ASP) mandate on methicillin-resistant Staphylococcus aureus (MRSA) and Clostridioides difficile infection (CDI) rates in acute-care hospitals. POPULATION Centers for Medicare and Medicaid Services (CMS)-certified acute-care hospitals in the United States. DATA SOURCES 2013-2017 data from the CMS Hospital Compare, Provider of Service File and Medicare Cost Reports. METHODS Difference-in-difference model with hospital fixed effects to compare California with all other states before and after the ASP mandate. We considered were standardized infection ratios (SIRs) for MRSA and CDI as the outcomes. We analyzed the following time-variant covariates: medical school affiliation, bed count, quality accreditation, number of changes in ownership, compliance with CMS requirements, % intensive care unit beds, average length of stay, patient safety index, and 30-day readmission rate. RESULTS In 2013, California hospitals had an average MRSA SIR of 0.79 versus 0.94 in other states, and an average CDI SIR of 1.01 versus 0.77 in other states. California hospitals had increases (P < .05) of 23%, 30%, and 20% in their MRSA SIRs in 2015, 2016, and 2017, respectively. California hospitals were associated with a 20% (P < .001) decrease in the CDI SIR only in 2017. CONCLUSIONS The mandate was associated with a decrease in CDI SIR and an increase in MRSA SIR.
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Barker AK, Scaria E, Safdar N, Alagoz O. Evaluation of the Cost-effectiveness of Infection Control Strategies to Reduce Hospital-Onset Clostridioides difficile Infection. JAMA Netw Open 2020; 3:e2012522. [PMID: 32789514 PMCID: PMC7426752 DOI: 10.1001/jamanetworkopen.2020.12522] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 05/25/2020] [Indexed: 12/14/2022] Open
Abstract
Importance Clostridioides difficile infection is the most common hospital-acquired infection in the United States, yet few studies have evaluated the cost-effectiveness of infection control initiatives targeting C difficile. Objective To compare the cost-effectiveness of 9 C difficile single intervention strategies and 8 multi-intervention bundles. Design, Setting, and Participants This economic evaluation was conducted in a simulated 200-bed tertiary, acute care, adult hospital. The study relied on clinical outcomes from a published agent-based simulation model of C difficile transmission. The model included 4 agent types (ie, patients, nurses, physicians, and visitors). Cost and utility estimates were derived from the literature. Interventions Daily sporicidal cleaning, terminal sporicidal cleaning, health care worker hand hygiene, patient hand hygiene, visitor hand hygiene, health care worker contact precautions, visitor contact precautions, C difficile screening at admission, and reduced intrahospital patient transfers. Main Outcomes and Measures Cost-effectiveness was evaluated from the hospital perspective and defined by 2 measures: cost per hospital-onset C difficile infection averted and cost per quality-adjusted life-year (QALY). Results In this agent-based model of a simulated 200-bed tertiary, acute care, adult hospital, 5 of 9 single intervention strategies were dominant, reducing cost, increasing QALYs, and averting hospital-onset C difficile infection compared with baseline standard hospital practices. They were daily cleaning (most cost-effective, saving $358 268 and 36.8 QALYs annually), health care worker hand hygiene, patient hand hygiene, terminal cleaning, and reducing intrahospital patient transfers. Screening at admission cost $1283/QALY, while health care worker contact precautions and visitor hand hygiene interventions cost $123 264/QALY and $5 730 987/QALY, respectively. Visitor contact precautions was dominated, with increased cost and decreased QALYs. Adding screening, health care worker hand hygiene, and patient hand hygiene sequentially to the daily cleaning intervention formed 2-pronged, 3-pronged, and 4-pronged multi-intervention bundles that cost an additional $29 616/QALY, $50 196/QALY, and $146 792/QALY, respectively. Conclusions and Relevance The findings of this study suggest that institutions should seek to streamline their infection control initiatives and prioritize a smaller number of highly cost-effective interventions. Daily sporicidal cleaning was among several cost-saving strategies that could be prioritized over minimally effective, costly strategies, such as visitor contact precautions.
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Affiliation(s)
- Anna K. Barker
- Department of Internal Medicine, University of Michigan, Ann Arbor
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison
| | - Elizabeth Scaria
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin–Madison
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Public Health, University of Wisconsin–Madison
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
| | - Oguzhan Alagoz
- Department of Population Health Sciences, School of Medicine and Public Health, University of Wisconsin–Madison
- Department of Industrial and Systems Engineering, College of Engineering, University of Wisconsin–Madison
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25
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Hamilton RM, Merrill KC, Luthy KE, Nuttall C. Knowledge, attitudes, and perceptions of nurse practitioners about antibiotic stewardship. J Am Assoc Nurse Pract 2020; 33:909-915. [PMID: 32740336 DOI: 10.1097/jxx.0000000000000467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/14/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Antibiotic stewardship (ABS) is a set of strategies to optimize antimicrobial use while reducing antibiotic resistance, improving patient outcomes, and decreasing unnecessary costs. Nurse practitioners (NPs) play an essential role in health care education and represent a valuable potential resource for ABS efforts. PURPOSE The purpose of this study was to describe the knowledge, attitudes, and perceptions of NPs toward ABS. METHODS A convenience sample of NPs attending the American Association of Nurse Practitioners annual conference was given a modified descriptive survey. Descriptive statistics were used to assess normality. RESULTS A total of 194 NPs completed the questionnaire (88% female; 70% master's degree). Factors affecting the decisions of antibiotic prescriptions included patient condition (79%) and patient cost (58%). Nurse practitioners based their antibiotic decisions on the antibiogram (63%) in their setting, whereas 56% indicated they start with broad spectrum and tailor antibiotic choices after cultures are received. Nurse practitioners understood that inappropriate antibiotic use causes resistance (97%), harms the patient (97%), and optimum antibiotic use will reduce resistance (94%). Participants also recognized that strong knowledge of antibiotics was important (94%) and felt confident in using antibiotics (86%). However, 94% agreed that antibiotics are overused nationally, and only 62% thought antibiotics were overused in their setting. IMPLICATIONS FOR PRACTICE Nurse practitioners recognize that knowledge about antibiotics is important to their career and would like more education about antibiotics and feedback about their antibiotic choices. Finding effective ways to provide this education could change practice and improve antibiotic use.
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Affiliation(s)
| | | | - Karlen E Luthy
- College of Nursing, Brigham Young University, Provo, Utah
| | - Craig Nuttall
- College of Nursing, Brigham Young University, Provo, Utah
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Avent ML, Cosgrove SE, Price-Haywood EG, van Driel ML. Antimicrobial stewardship in the primary care setting: from dream to reality? BMC FAMILY PRACTICE 2020; 21:134. [PMID: 32641063 PMCID: PMC7346425 DOI: 10.1186/s12875-020-01191-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Accepted: 06/15/2020] [Indexed: 12/03/2022]
Abstract
BACKGROUND Clinicians who work in primary care are potentially the most influential healthcare professionals to address the problem of antibiotic resistance because this is where most antibiotics are prescribed. Despite a number of evidence based interventions targeting the management of community infections, the inappropriate antibiotic prescribing rates remain high. DISCUSSION The question is how can appropriate prescribing of antibiotics through the use of Antimicrobial Stewardship (AMS) programs be successfully implemented in primary care. We discuss that a top-down approach utilising a combination of strategies to ensure the sustainable implementation and uptake of AMS interventions in the community is necessary to support clinicians and ensure a robust implementation of AMS in primary care. Specifically, we recommend a national accreditation standard linked to the framework of Core Elements of Outpatient Antibiotic Stewardship, supported by resources to fund the implementation of AMS interventions that are connected to quality improvement initiatives. This article debates how this can be achieved. The paper highlights that in order to support the sustainable uptake of AMS programs in primary care, an approach similar to the hospital and post-acute care settings needs to be adopted, utilising a combination of behavioural and regulatory processes supported by sustainable funding. Without these strategies the problem of inappropriate antibiotic prescribing will not be adequately addressed in the community and the successful implementation and uptake of AMS programs will remain a dream.
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Affiliation(s)
- M L Avent
- Statewide Antimicrobial Stewardship Program, Queensland Health, Brisbane, Australia.
- UQ Centre for Clinical Research (UQCCR), The University of Queensland, Brisbane, Australia.
| | - S E Cosgrove
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - E G Price-Haywood
- Ochsner Health System, Center for Outcomes and Health Services Research, New Orleans, Louisiana, USA
- Ochnser Clinical School, The University of Queensland, New Orleans, Louisiana, USA
| | - M L van Driel
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
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Variation in Prescribing and Factors Associated With the Use of Prophylactic Antibiotics for Mohs Surgery: A Single-Institution Retrospective Study. Dermatol Surg 2020; 46:868-875. [DOI: 10.1097/dss.0000000000002203] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Using deep learning and Twitter data to identify outpatient antibiotic misuse. Infect Control Hosp Epidemiol 2020; 41:1096-1098. [PMID: 32624033 DOI: 10.1017/ice.2020.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Miller MQ, Stevens JS, Park SS, Christophel JJ. Do Postoperative Antibiotics Affect Outcomes in Mohs Reconstructive Surgery? Laryngoscope 2020; 131:E434-E439. [PMID: 32401393 DOI: 10.1002/lary.28700] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/28/2020] [Accepted: 04/03/2020] [Indexed: 11/09/2022]
Abstract
OBJECTIVES/HYPOTHESIS The prescribing of postoperative antibiotics for patients undergoing Mohs reconstructive surgery has increased in the last decade, while antibiotic resistance has been increasing. We hypothesized that routine prescribing of postoperative antibiotics after Mohs reconstruction does not decrease the risk of surgical site infection. STUDY DESIGN Retrospective, single-institution cohort study. METHODS This study assessed patients who underwent Mohs reconstructive surgery from January 1, 2012, to January 29, 2019. The main outcomes assessed included postoperative surgical site infections, partial or full flap/graft necrosis, hematoma, and dehiscence. RESULTS A total of 900 defects in 800 patients (mean age [range] = 65.3 [21-96], 54.60% female) were identified over the 7-year period. Patient-specific variables reviewed included comorbidities, age, and smoking status. Surgery-specific variables analyzed included defect characteristics, time interval between Mohs micrographic surgery and reconstruction, reconstructive modalities, and use of postoperative antibiotics. All patients received peri-incisional antibiotics. On regression analysis, use of cartilage grafts (odds ratio [OR]: 6.53; 95% CI: 2.1-20.6; P = .001), current smoking status (OR: 6.67; 95% CI: 2.09-21.30; P = .001), full-thickness defects (OR: 1.2; 95% CI: 1.0-3.4; P = .045), and interpolated flap reconstruction (OR: 3.4; 95% CI: 1.0-11.5; P = .049) were associated with an increased risk of postoperative infections. Smoking and cartilage grafting remained significant on bivariable regression modeling. Use of perioperative antibiotics was not associated with a decreased risk of infection (OR: 1.82; 95% CI: 0.23-14.21; P = .568). CONCLUSIONS We found no association between postoperative infections after Mohs reconstructive surgery and the use of postoperative antibiotics. These data support a more targeted approach to antibiotic prescribing in Mohs reconstructive surgery. LEVEL OF EVIDENCE 4 Laryngoscope, 131:E434-E439, 2021.
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Affiliation(s)
- Matthew Q Miller
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | | | - Stephen S Park
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
| | - J Jared Christophel
- Department of Otolaryngology-Head and Neck Surgery, University of Virginia, Charlottesville, Virginia, U.S.A
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Barbieri JS, Bhate K, Hartnett KP, Fleming-Dutra KE, Margolis DJ. Trends in Oral Antibiotic Prescription in Dermatology, 2008 to 2016. JAMA Dermatol 2020; 155:290-297. [PMID: 30649187 DOI: 10.1001/jamadermatol.2018.4944] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Dermatologists prescribe more oral antibiotic courses per clinician than any other specialty, and this use puts patients at risk of antibiotic-resistant infections and antibiotic-associated adverse events. Objective To characterize the temporal trends in the diagnoses most commonly associated with oral antibiotic prescription by dermatologists, as well as the duration of this use. Design, Setting, and Participants Repeated cross-sectional analysis of antibiotic prescribing by dermatologists from January 1, 2008, to December 31, 2016. The setting was Optum Clinformatics Data Mart (Eden Prairie, Minnesota) deidentified commercial claims data. Participants were dermatology clinicians identified by their National Uniform Claim Committee taxonomy codes, and courses of oral antibiotics prescribed by these clinicians were identified by their National Drug Codes. Exposures Claims for oral antibiotic prescriptions were consolidated into courses of therapy and associated with the primary diagnosis from the most recent visit. Courses were stratified into those of extended duration (>28 days) and those of short duration (≤28 days). Main Outcomes and Measures Frequency of antibiotic prescribing and associated diagnoses. Poisson regression models were used to assess for changes in the frequency of antibiotic prescribing over time. Results Between 2008 and 2016 among 985 866 courses of oral antibiotics prescribed by 11 986 unique dermatologists, overall antibiotic prescribing among dermatologists decreased 36.6% (1.23 courses per 100 visits) from 3.36 (95% CI, 3.34-3.38) to 2.13 (95% CI, 2.12-2.14) courses per 100 visits with a dermatologist (prevalence rate ratio for annual change, 0.931; 95% CI, 0.930-0.932), with much of this decrease occurring among extended courses for acne and rosacea. Oral antibiotic use associated with surgical visits increased 69.6% (2.73 courses per 100 visits) from 3.92 (95% CI, 3.83-4.01) to 6.65 (95% CI, 6.57-6.74) courses per 100 visits associated with a surgical visit (prevalence rate ratio, 1.061; 95% CI, 1.059-1.063). Conclusions and Relevance Continuing to develop alternatives to oral antibiotics for noninfectious conditions, such as acne, can improve antibiotic stewardship and decrease complications from antibiotic use. In addition, the rising use of postoperative antibiotics after surgical visits is concerning and may put patients at unnecessary risk of adverse events. Future studies are needed to identify the value of this practice and the risk of adverse events.
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Affiliation(s)
- John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Ketaki Bhate
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Kathleen P Hartnett
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia.,Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia.,United States Public Health Service Commissioned Corps, Rockville, Maryland
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Barbieri JS, Etzkorn JR, Margolis DJ. Use of Antibiotics for Dermatologic Procedures From 2008 to 2016. JAMA Dermatol 2020; 155:465-470. [PMID: 30825412 DOI: 10.1001/jamadermatol.2019.0152] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Although overall antibiotic use among dermatologists is decreasing, there has been an increase in use associated with dermatologic procedures during the past decade. This higher antibiotic use may increase antibiotic-associated adverse events and promote the development of antibiotic resistance. Objective To characterize antibiotic use associated with dermatologic procedures, including geographic variation. Design, Setting, and Participants Using Optum Clinformatics DataMart deidentified commercial claims data, we performed a repeated cross-sectional analysis of antibiotic prescribing by dermatologists from 2008 to 2016. Dermatology clinicians were identified by their National Uniform Claim Committee taxonomy codes, encounters for surgical procedures were identified by Common Procedure Terminology codes, and courses of oral antibiotics prescribed by these clinicians were identified by their National Drug Codes. Exposures Claims for oral antibiotic prescriptions associated with encounters with dermatologists associated with dermatologic procedures. Main Outcomes and Measures Frequency of antibiotic prescribing and associated procedures. Poisson regression models were used to assess for changes in the frequency of antibiotic prescribing over time. Results Between 2008 and 2016, among 1 934 633 encounters (1 128 244 unique patients, 854 072 [44.1%] were women and the median [interquartile range] age was 66 [52-76] years) for dermatologic procedures, oral antibiotic prescribing associated with benign excisions increased from 2.9% to 4.4% of visits (52.5% relative change; incidence rate ratio [IRR], 1.04; 95% CI, 1.03-1.04), antibiotic prescribing associated with malignant excisions increased from 4.2% to 6.3% of visits (49.5% relative change; IRR, 1.06; 95% CI, 1.05-1.06), and antibiotic prescribing associated with Mohs surgery increased from 9.9% to 13.8% of visits (39.7% relative change; IRR, 1.04; 95% CI, 1.03-1.04). There was greater than 2-fold variation in antibiotic prescribing rates across geographic census divisions. If higher prescribing divisions were to develop antibiotic prescribing rates similar to lower prescribing divisions, antibiotic use could be decreased by over 50%. Conclusions and Relevance Oral antibiotic prescribing by dermatologists associated with benign excisions, malignant excisions, and Mohs surgery is increasing over the past decade and there is substantial geographic variation. These findings highlight that there may be opportunities to optimize antibiotic use associated with dermatologic procedures.
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Affiliation(s)
- John S Barbieri
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Jeremy R Etzkorn
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Associate Editor
| | - David J Margolis
- Department of Dermatology, University of Pennsylvania Perelman School of Medicine, Philadelphia.,Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Association between statewide adoption of the CDC's Core Elements of Hospital Antimicrobial Stewardship Programs and rates of methicillin-resistant Staphylococcus aureus bacteremia and Clostridioides difficile infection in the United States. Infect Control Hosp Epidemiol 2019; 41:430-437. [PMID: 31858919 DOI: 10.1017/ice.2019.352] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To measure the association between statewide adoption of the Centers for Disease Control and Prevention's (CDC's) Core Elements for Hospital Antimicrobial Stewardship Programs (Core Elements) and hospital-associated methicillin-resistant Staphylococcus aureus bacteremia (MRSA) and Clostridioides difficile infection (CDI) rates in the United States. We hypothesized that states with a higher percentage of reported compliance with the Core Elements have significantly lower MRSA and CDI rates. PARTICIPANTS All US states. DESIGN Observational longitudinal study. METHODS We used 2014-2016 data from Hospital Compare, Provider of Service files, Medicare cost reports, and the CDC's Patient Safety Atlas website. Outcomes were MRSA standardized infection ratio (SIR) and CDI SIR. The key explanatory variable was the percentage of hospitals that meet the Core Elements in each state. We estimated state and time fixed-effects models with time-variant controls, and we weighted our analyses for the number of hospitals in the state. RESULTS The percentage of hospitals reporting compliance with the Core Elements between 2014 and 2016 increased in all states. A 1% increase in reported ASP compliance was associated with a 0.3% decrease (P < .01) in CDIs in 2016 relative to 2014. We did not find an association for MRSA infections. CONCLUSIONS Increasing documentation of the Core Elements may be associated with decreases in the CDI SIR. We did not find evidence of such an association for the MRSA SIR, probably due to the short length of the study and variety of stewardship strategies that ASPs may encompass.
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Validating a popular outpatient antibiotic database to reliably identify high prescribing physicians for patients 65 years of age and older. PLoS One 2019; 14:e0223097. [PMID: 31557249 PMCID: PMC6762161 DOI: 10.1371/journal.pone.0223097] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Accepted: 09/13/2019] [Indexed: 12/14/2022] Open
Abstract
Objective Many jurisdictions lack comprehensive population-based antibiotic use data and rely on third party companies, most commonly IQVIA. Our objective was to validate the accuracy of the IQVIA Xponent antibiotic database in identifying high prescribing physicians compared to the reference standard of a highly accurate population-wide database of outpatient antimicrobial dispensing for patients ≥65 years. Methods We conducted this study between 1 March 2016 and 28 February 2017 in Ontario, Canada. We evaluated the agreement and correlation between the databases using kappa statistics and Bland-Altman plots. We also assessed performance characteristics for Xponent to accurately identify high prescribing physicians with sensitivity, specificity, positive predictive value (PPV), and negative predictive value. Results We included 9,272 physicians. The Xponent database has a specificity of 92.4% (95%CI 92.0%-92.8%) and PPV of 77.2% (95%CI 76.0%-78.4%) for correctly identifying the top 25th percentile of physicians by antibiotic volume. In the sensitivity analysis, 94% of the top 25th percentile physicians in Xponent were within the top 40th percentile in the reference database. The mean number of antibiotic prescriptions per physician were similar with a relative difference of -0.4% and 2.7% for female and male patients, respectively. The error was greater in rural areas with a relative difference of -8.4% and -5.6% per physician for female and male patients, respectively. The weighted kappa for quartile agreement was 0.68 (95%CI 0.67–0.69). Conclusion We validated the IQVIA Xponent antibiotic database to identify high prescribing physicians for patients ≥65 years, and identified some important limitations. Collecting accurate population-based antibiotic use data will remain vital to global antimicrobial stewardship efforts.
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Incidence of Clostridioides difficile infections among young and middle-aged adults: Veterans Health Administration. Infect Control Hosp Epidemiol 2019; 40:997-1005. [DOI: 10.1017/ice.2019.160] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
AbstractObjective:Clostridioides difficile infection (CDI) remains a significant public health concern, resulting in excess morbidity, mortality, and costs. Additional insight into the burden of CDI in adults aged <65 years is needed.Design/Setting:A 6-year retrospective cohort study was conducted using data extracted from United States Veterans Health Administration electronic medical records.Patients/Methods:Patients aged 18–64 years on January 1, 2011, were followed until incident CDI, death, loss-to-follow-up, or December 31, 2016. CDI was identified by a diagnosis code accompanied by metronidazole, vancomycin, or fidaxomicin therapy, or positive laboratory test. The clinical setting of CDI onset was defined according to 2017 SHEA-IDSA guidelines.Results:Of 1,073,900 patients, 10,534 had a CDI during follow-up. The overall incidence rate was 177 CDIs per 100,000 person years, rising steadily from 164 per 100,000 person years in 2011 to 189 per 100,000 person years in 2016. Those with a CDI were slightly older (55 vs 51 years) and sicker, with a higher baseline Charlson comorbidity index score (1.4 vs 0.5) than those without an infection. Nearly half (48%) of all incident CDIs were community associated, and this proportion rose from 41% in 2011 to 56% in 2016.Conclusions:The findings from this large retrospective study indicate that CDI incidence, driven primarily by increasing community-associated infection, is rising among young and middle-aged adult Veterans with high service-related disability. The increasing burden of community associated CDI in this vulnerable population warrants attention. Future studies quantifying the economic and societal burden of CDI will inform decisions surrounding prevention strategies.
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Factors affecting the geographic variability of antibiotic-resistant healthcare-associated infections in the United States using the CDC Antibiotic Resistance Patient Safety Atlas. Infect Control Hosp Epidemiol 2019; 40:597-599. [PMID: 30975229 DOI: 10.1017/ice.2019.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We utilized publicly available data from the Centers for Disease Control to explore possible causes of state-to-state variability in antibiotic-resistant healthcare-associated infections. Outpatient antibiotic prescribing rates of fluoroquinolones and cephalosporins explained some variability in extended-spectrum cephalosporin-resistant Escherichia coli after adjusting for differences in age and healthcare facility composition.
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Gross AE, Hanna D, Rowan SA, Bleasdale SC, Suda KJ. Successful Implementation of an Antibiotic Stewardship Program in an Academic Dental Practice. Open Forum Infect Dis 2019; 6:ofz067. [PMID: 30895206 PMCID: PMC6419992 DOI: 10.1093/ofid/ofz067] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Accepted: 02/10/2019] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Most antibiotic use in the United States occurs in the outpatient setting, and 10% of these prescriptions are generated by dentists. The development of comprehensive antibiotic stewardship programs (ASPs) in the dental setting is nascent, and therefore we describe the implementation of a dental ASP. METHODS A collaborative team of dentist, pharmacist, and physician leaders conducted a baseline needs assessment and literature evaluation to identify opportunities to improve antibiotic prescribing by dentists within Illinois' largest oral health care provider for Medicaid recipients. A multimodal intervention was implemented that included patient and provider education, clinical guideline development, and an assessment of the antibiotic prescribing rate per urgent care visit before and after the educational interventions. RESULTS We identified multiple needs, including standardization of antibiotic prescribing practices for patients with acute oral infections in the urgent care clinics. A 72.9% decrease in antibiotic prescribing was observed in urgent care visits after implementation of our multimodal intervention (preintervention urgent care prescribing rate, 8.5% [24/283]; postintervention, 2.3% [8/352]; P < .001). CONCLUSIONS We report the successful implementation of a dental ASP that is concordant with the Centers for Disease Control and Prevention Core Elements of Antibiotic Stewardship in the Outpatient Setting. Our approach may be adapted to other dental practices to improve antibiotic prescribing.
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Affiliation(s)
- Alan E Gross
- Department of Pharmacy Practice, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
- Hospital Pharmacy Services, University of Illinois Hospital and Health Sciences System, Chicago, Illinois
| | - Danny Hanna
- Department of Oral Medicine and Diagnostic Sciences, University of Illinois at Chicago College of Dentistry, Chicago, Illinois
| | - Susan A Rowan
- Department of Restorative Dentistry, University of Illinois at Chicago College of Dentistry, Chicago, Illinois
| | - Susan C Bleasdale
- Internal Medicine, Division of Infectious Diseases, University of Illinois at Chicago, Chicago, Illinois
| | - Katie J Suda
- Department of Pharmacy Systems, Outcomes & Policy, University of Illinois at Chicago College of Pharmacy, Chicago, Illinois
- Center of Innovation for Complex Chronic Healthcare (CINCCH), Department of Veterans Affairs, Edward Hines Jr VA Hospital, Hines, Illinois
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Haque M, Che Roos N, Bakar M. Knowledge, attitude and practice among Malaysian medical students, doctors, other health professionals and common people regarding antibiotic use, prescribing and resistance: A systematic review. ADVANCES IN HUMAN BIOLOGY 2019. [DOI: 10.4103/aihb.aihb_42_19] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Abstract
The inappropriate use of antibiotics can increase the likelihood of antibiotic resistance and adverse events. In the United States, nearly a third of antibiotic prescriptions in outpatient settings are unnecessary, and the selection of antibiotics and duration of treatment are also often inappropriate. Evidence shows that antibiotic prescribing is influenced by psychosocial factors, including lack of accountability, perceived patient expectations, clinician workload, and habit. A varied and growing body of evidence, including meta-analyses and randomized controlled trials, has evaluated interventions to optimize the use of antibiotics. Interventions informed by behavioral science-such as communication skills training, audit and feedback with peer comparison, public commitment posters, and accountable justification-have been associated with improved antibiotic prescribing. In addition, delayed prescribing, active monitoring, and the use of diagnostics are guideline recommended practices that improve antibiotic use for some conditions. In 2016, the Centers for Disease Control and Prevention released the Core Elements of Outpatient Antibiotic Stewardship, which provides a framework for implementing these interventions in outpatient settings. This review summarizes the varied evidence on drivers of inappropriate prescription of antibiotics in outpatient settings and potential interventions to improve their use in such settings.
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Affiliation(s)
- Laura M King
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Katherine E Fleming-Dutra
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
| | - Lauri A Hicks
- Division of Healthcare Quality Promotion, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Mailstop H16-3, Atlanta, GA, 30329, US
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Zheng W, Wang K, Sun Y, Kuo SM. Dietary or supplemental fermentable fiber intake reduces the presence of Clostridium XI in mouse intestinal microbiota: The importance of higher fecal bacterial load and density. PLoS One 2018; 13:e0205055. [PMID: 30278071 PMCID: PMC6168175 DOI: 10.1371/journal.pone.0205055] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/19/2018] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES Clostridium difficile infection is a public health concern. C. difficile was found in healthy human intestine as a member of Clostridium XI. Because soluble fermentable fiber ingestion affects intestinal microbiota, we used fiber-containing diets to determine the intestinal microbial condition that could reduce the presence of Clostridium XI. METHODS Newly weaned male mice were assigned to three published diets: Control AIN-93G purified diet with only poorly fermented cellulose; Control plus 5% purified fermentable fiber inulin; Chow with wheat, soybean and corn that provide a mixture of unpurified dietary fibers. Methods were developed to quantify 24-hour fecal microbial load and microbial DNA density. The relative abundance of bacterial genera and the bacterial diversity were determined through 16S rRNA sequence-based fecal microbiota analysis. RESULTS Mice adjusted food intake to maintain the same energy intake and body weight under these three moderate-fat (7% w:w) diets. Chow-feeding led to higher food intake but also higher 24-h fecal output. Chow-feeding and 1-8 wk ingestion of inulin-supplemented diet increased daily fecal microbial load and density along with lowering the prevalence of Clostridium XI to undetectable. Clostridium XI remained undetectable until 4 weeks after the termination of inulin-supplemented diet. Fermentable fiber intake did not consistently increase probiotic genera such as Bifidobacterium or Lactobacillus. Chow feeding, but not inulin supplementation, increased the bacterial diversity. CONCLUSIONS Increase fecal microbial load/density upon fermentable fiber ingestion is associated with a lower and eventually undetectable presence of Clostridium XI. Higher bacterial diversity or abundance of particular genera is not apparently essential. Future studies are needed to see whether this observation can be translated into the reduction of C. difficile at the species level in at-risk populations.
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Affiliation(s)
- Wei Zheng
- Department of Computer Science and Engineering, University at Buffalo, Buffalo, NY, United States of America
| | - Kairui Wang
- Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, United States of America
| | - Yijun Sun
- Department of Computer Science and Engineering, University at Buffalo, Buffalo, NY, United States of America
- Department of Microbiology and Immunology, University at Buffalo, Buffalo, NY, United States of America
- Department of Biostatistics, University at Buffalo, Buffalo, NY, United States of America
| | - Shiu-Ming Kuo
- Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY, United States of America
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Schwartz KL, Achonu C, Brown KA, Langford B, Daneman N, Johnstone J, Garber G. Regional variability in outpatient antibiotic use in Ontario, Canada: a retrospective cross-sectional study. CMAJ Open 2018; 6:E445-E452. [PMID: 30381321 PMCID: PMC6208056 DOI: 10.9778/cmajo.20180017] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Regional variability in antibiotic use is associated with both antibiotic overuse and antimicrobial resistance. Our objectives were to benchmark outpatient antibiotic use and to evaluate geographic variability among health regions in the province of Ontario, Canada. METHODS This was a cross-sectional study of antibiotics dispensed from outpatient retail pharmacies in Ontario between March 2016 and February 2017. We analyzed variability in the number of antibiotic prescriptions dispensed per 1000 population among Ontario's 14 health regions with crude and adjusted Poisson regression models. Adjusted models controlled for rurality, 4 physician characteristics and 6 population characteristics. RESULTS There were 8 352 578 antibiotics dispensed during the 1-year study period or 621 per 1000 population. The most commonly prescribed antibiotic classes were narrow-spectrum penicillins, macrolides, first-generation cephalosporins and second-generation fluoroquinolones, with adult women receiving the highest rate of prescriptions: 985 antibiotic prescriptions per 1000 population. There was geographic variability in total and class-specific antibiotic use. In the health region with the highest use 778 antibiotics were dispensed per 1000 population whereas in the health region with the lowest use 534 antibiotics were dispensed per 1000 population. The adjusted marginal standardized antibiotic prescription rates for the health regions with the highest and lowest use were 787 (95% confidence interval [CI] 658-934) and 546 (95% CI 494-606) antibiotic prescriptions per 1000 population, respectively. INTERPRETATION We described baseline antibiotic usage in Ontario over a 12-month period, noting variability among some health regions. Our findings highlight the need for interventions to optimize antibiotic use and slow the emergence of antimicrobial resistance.
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Affiliation(s)
- Kevin L Schwartz
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont.
| | - Camille Achonu
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Kevin Antoine Brown
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Bradley Langford
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Nick Daneman
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Jennie Johnstone
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
| | - Gary Garber
- Public Health Ontario (Schwartz, Achonu, Brown, Langford, Daneman, Johnstone, Garber); Dalla Lana School of Public Health (Schwartz, Brown, Johnstone); Sunnybrook Health Sciences Centre (Daneman); Department of Medicine (Daneman, Garber), University of Toronto, Toronto, Ont.; Ottawa Hospital Research Institute (Garber), Ottawa, Ont
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Zetts RM, Stoesz A, Smith BA, Hyun DY. Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts. Pediatrics 2018; 141:peds.2017-4124. [PMID: 29793986 DOI: 10.1542/peds.2017-4124] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/27/2018] [Indexed: 11/24/2022] Open
Abstract
Antibiotic-resistant infections pose a growing threat to public health. Antibiotic use, regardless of whether it is warranted, is a primary factor in the development of resistance. In the United States, the majority of antibiotic health care expenditures are due to prescribing in outpatient settings. Much of this prescribing is inappropriate, with research showing that at least 30% of antibiotic use in outpatient settings is unnecessary. In this State of the Art Review article, we provide an overview of the latest research on outpatient antibiotic prescribing practices in the United States. Although many of the researchers in these studies describe antibiotic prescribing across all patient age groups, we highlight prescribing in pediatric populations when data are available. We then describe the various factors that can influence a physician's prescribing decisions and drive inappropriate antibiotic use and the potential role of behavioral science in enhancing stewardship interventions to address these drivers. Finally, we highlight the role that a wide range of health care stakeholders can play in aiding the expansion of outpatient stewardship efforts that are needed to fully address the threat of antibiotic resistance.
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Affiliation(s)
- Rachel M Zetts
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Andrea Stoesz
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - Brian A Smith
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
| | - David Y Hyun
- Antibiotic Resistance Project, The Pew Charitable Trusts, Washington, District of Columbia
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Barker AK, Alagoz O, Safdar N. Interventions to Reduce the Incidence of Hospital-Onset Clostridium difficile Infection: An Agent-Based Modeling Approach to Evaluate Clinical Effectiveness in Adult Acute Care Hospitals. Clin Infect Dis 2018; 66:1192-1203. [PMID: 29112710 PMCID: PMC5888988 DOI: 10.1093/cid/cix962] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 10/31/2017] [Indexed: 12/18/2022] Open
Abstract
Background Despite intensified efforts to reduce hospital-onset Clostridium difficile infection (HO-CDI), its clinical and economic impacts continue to worsen. Many institutions have adopted bundled interventions that vary considerably in composition, strength of evidence, and effectiveness. Considerable gaps remain in our knowledge of intervention effectiveness and disease transmission, which hinders HO-CDI prevention. Methods We developed an agent-based model of C. difficile transmission in a 200-bed adult hospital using studies from the literature, supplemented with primary data collection. The model includes an environmental component and 4 distinct agent types: patients, visitors, nurses, and physicians. We used the model to evaluate the comparative clinical effectiveness of 9 single interventions and 8 multiple-intervention bundles at reducing HO-CDI and asymptomatic C. difficile colonization. Results Daily cleaning with sporicidal disinfectant and C. difficile screening at admission were the most effective single-intervention strategies, reducing HO-CDI by 68.9% and 35.7%, respectively (both P < .001). Combining these interventions into a 2-intervention bundle reduced HO-CDI by 82.3% and asymptomatic hospital-onset colonization by 90.6% (both, P < .001). Adding patient hand hygiene to healthcare worker hand hygiene reduced HO-CDI rates an additional 7.9%. Visitor hand hygiene and contact precaution interventions did not reduce HO-CDI, compared with baseline. Excluding those strategies, healthcare worker contact precautions were the least effective intervention at reducing hospital-onset colonization and infection. Conclusions Identifying and managing the vast hospital reservoir of asymptomatic C. difficile by screening and daily cleaning with sporicidal disinfectant are high-yield strategies. These findings provide much-needed data regarding which interventions to prioritize for optimal C. difficile control.
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Affiliation(s)
- Anna K Barker
- Department of Population Health Sciences, School of Medicine and Public Health, Madison, Wisconsin
| | - Oguzhan Alagoz
- Department of Population Health Sciences, School of Medicine and Public Health, Madison, Wisconsin
- Department of Industrial and Systems Engineering, College of Engineering, Madison, Wisconsin
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, School of Medicine and Public Health, University of Wisconsin–Madison, Madison, Wisconsin
- William S. Middleton Memorial Veterans Hospital, Madison, Wisconsin
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Antimicrobial Stewardship Efforts to Improve Management of Uncomplicated Urinary Tract Infections in the Ambulatory Care Setting: a Review. CURRENT TREATMENT OPTIONS IN INFECTIOUS DISEASES 2018. [DOI: 10.1007/s40506-018-0150-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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44
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Suda KJ, Livorsi DJ, Goto M, Forrest GN, Jones MM, Neuhauser MM, Hoff BM, Ince D, Carrel M, Nair R, Knobloch MJ, Goetz MB. Research Agenda for Antimicrobial Stewardship in the Veterans Health Administration. Infect Control Hosp Epidemiol 2018; 39:196-201. [PMID: 29417925 PMCID: PMC9793410 DOI: 10.1017/ice.2017.299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Antimicrobial stewardship is vital to reducing the spread of antimicrobial resistance. A group of investigators and clinicians within the Veterans Health Administration set forth a research agenda for antimicrobial stewardship, including research targets for inpatient and outpatient stewardship activities, metrics, and antimicrobial dosing and duration.
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Affiliation(s)
- Katie J Suda
- 1Center of Innovation for Complex Chronic Healthcare,Edward Hines Jr VA Hospital,Hines,IL
| | | | | | | | - Makoto M Jones
- 6VA Salt Lake City Health Care System and the University of Utah School of Medicine,Salt Lake City,Utah
| | | | - Brian M Hoff
- 8University of Iowa Hospital and Clinics,Iowa City,Iowa
| | - Dilek Ince
- 4Division of Infectious Diseases,Department of Internal Medicine,University of Iowa Carver College of Medicine,Iowa City,Iowa
| | - Margaret Carrel
- 9Department of Geographical and Sustainability Sciences,College of Liberal Arts and Sciences,University of Iowa,Iowa City,Iowa
| | | | - Mary Jo Knobloch
- 10University of Wisconsin School of Medicine and Public Health,Madison, Wisconsin and the William S. Middleton Memorial Veterans Hospital,Madison Wisconsin
| | - Matthew B Goetz
- 11VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA,Los Angeles,California
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45
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Tan C, Graves E, Lu H, Chen A, Li S, Schwartz KL, Daneman N. A decade of outpatient antimicrobial use in older adults in Ontario: a descriptive study. CMAJ Open 2017; 5:E878-E885. [PMID: 29273579 PMCID: PMC5741418 DOI: 10.9778/cmajo.20170100] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antimicrobials are frequently prescribed to community-dwelling older adults. Our aim was to examine the prevalence, quantity and indications of antimicrobial prescriptions to older residents of Ontario. METHODS We conducted a population-based analysis of outpatient antimicrobial prescriptions to residents of Ontario aged 65 years or more from 2006 to 2015. Antimicrobial prescriptions, infectious disease diagnoses and prescriber information were determined from linked health care databases. Our analyses were primarily focused on antibiotics, which account for most antimicrobial use. RESULTS We identified 2 879 779 unique Ontario residents aged 65 years or more over our study period. On average, 40.7% (range 40.1%-41.5%) of older adult outpatients in any given year received 1 or more antibiotic prescriptions. Antibiotic use remained stable over the study period, averaging 25.1 (range 24.1-25.6) defined daily doses per 1000 person-days per year. Selection of antibiotics evolved, with increasing use of penicillins and decreasing use of fluoroquinolones and macrolides. For 65.7% of prescriptions, no infectious disease diagnoses were identified within 7 days of the prescription. Among prescriptions with an associated diagnosis, upper respiratory tract infection was most common (18.9%), followed by urinary tract infection (6.2%), skin/soft-tissue infection (4.3%), lower respiratory tract infection (4.2%) and other infection (1.2%). Most antibiotics were prescribed by family physicians. INTERPRETATION Antibiotic use among older adult outpatients in Ontario remained stable between 2006 and 2015. Current methods of measuring use are not capable of accurately determining indication, and, thus, additional data sources to monitor the appropriateness of community antimicrobial use are needed.
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Affiliation(s)
- Charlie Tan
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Erin Graves
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Hong Lu
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Anna Chen
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Shudong Li
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Kevin L Schwartz
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
| | - Nick Daneman
- Affiliations: Sunnybrook Research Institute (Tan, Daneman) and Division of Infectious Diseases (Daneman), Sunnybrook Health Sciences Centre; Institute for Clinical Evaluative Sciences (Graves, Lu, Chen, Li, Schwartz, Daneman); Public Health Ontario (Schwartz, Daneman); Dalla Lana School of Public Health (Schwartz), University of Toronto, Toronto, Ont
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Guh AY, Adkins SH, Li Q, Bulens SN, Farley MM, Smith Z, Holzbauer SM, Whitten T, Phipps EC, Hancock EB, Dumyati G, Concannon C, Kainer MA, Rue B, Lyons C, Olson DM, Wilson L, Perlmutter R, Winston LG, Parker E, Bamberg W, Beldavs ZG, Ocampo V, Karlsson M, Gerding DN, McDonald LC. Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study. Open Forum Infect Dis 2017; 4:ofx171. [PMID: 29732377 PMCID: PMC5903408 DOI: 10.1093/ofid/ofx171] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2017] [Accepted: 08/08/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND An increasing proportion of Clostridium difficile infections (CDI) in the United States are community-associated (CA). We conducted a case-control study to identify CA-CDI risk factors. METHODS We enrolled participants from 10 US sites during October 2014-March 2015. Case patients were defined as persons age ≥18 years with a positive C. difficile specimen collected as an outpatient or within 3 days of hospitalization who had no admission to a health care facility in the prior 12 weeks and no prior CDI diagnosis. Each case patient was matched to one control (persons without CDI). Participants were interviewed about relevant exposures; multivariate conditional logistic regression was performed. RESULTS Of 226 pairs, 70.4% were female and 52.2% were ≥60 years old. More case patients than controls had prior outpatient health care (82.1% vs 57.9%; P < .0001) and antibiotic (62.2% vs 10.3%; P < .0001) exposures. In multivariate analysis, antibiotic exposure-that is, cephalosporin (adjusted matched odds ratio [AmOR], 19.02; 95% CI, 1.13-321.39), clindamycin (AmOR, 35.31; 95% CI, 4.01-311.14), fluoroquinolone (AmOR, 30.71; 95% CI, 2.77-340.05) and beta-lactam and/or beta-lactamase inhibitor combination (AmOR, 9.87; 95% CI, 2.76-340.05),-emergency department visit (AmOR, 17.37; 95% CI, 1.99-151.22), white race (AmOR 7.67; 95% CI, 2.34-25.20), cardiac disease (AmOR, 4.87; 95% CI, 1.20-19.80), chronic kidney disease (AmOR, 12.12; 95% CI, 1.24-118.89), and inflammatory bowel disease (AmOR, 5.13; 95% CI, 1.27-20.79) were associated with CA-CDI. CONCLUSIONS Antibiotics remain an important risk factor for CA-CDI, underscoring the importance of appropriate outpatient prescribing. Emergency departments might be an environmental source of CDI; further investigation of their contribution to CDI transmission is needed.
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Affiliation(s)
- Alice Y Guh
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Susan Hocevar Adkins
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Qunna Li
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Sandra N Bulens
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Monica M Farley
- Emory University Department of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Decatur, Georgia
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
| | - Zirka Smith
- Georgia Emerging Infections Program, Decatur, Georgia
- Atlanta Veterans Affairs Medical Center, Atlanta, Georgia
- Atlanta Research and Education Foundation, Decatur, Georgia
| | - Stacy M Holzbauer
- Minnesota Department of Health, St Paul, Minnesota
- Career Epidemiology Field Officer Program, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tory Whitten
- Minnesota Department of Health, St Paul, Minnesota
| | - Erin C Phipps
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Emily B Hancock
- University of New Mexico, New Mexico Emerging Infections Program, Albuquerque, New Mexico
| | - Ghinwa Dumyati
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | - Cathleen Concannon
- New York Emerging Infections Program and University of Rochester Medical Center, Rochester, New York
| | | | - Brenda Rue
- Tennessee Department of Health, Nashville, Tennessee
| | - Carol Lyons
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Danyel M Olson
- Yale School of Public Health, Connecticut Emerging Infections Program, New Haven, Connecticut
| | - Lucy Wilson
- Maryland Department of Health and Mental Hygiene, Baltimore, Maryland
| | | | - Lisa G Winston
- University of California, San Francisco, School of Medicine, San Francisco, California
| | - Erin Parker
- California Emerging Infections Program, Oakland, California
| | - Wendy Bamberg
- Colorado Department of Public Health and Environment, Denver, Colorado
| | | | | | - Maria Karlsson
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dale N Gerding
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
- Edward Hines, Jr. Veterans Affairs Hospital, Hines, Illinois
| | - L Clifford McDonald
- Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, Atlanta, Georgia
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McGowan JE. The 2016 Garrod Lecture: The role of the healthcare epidemiologist in antimicrobial chemotherapy-a view from the USA. J Antimicrob Chemother 2017; 71:2370-8. [PMID: 27550989 DOI: 10.1093/jac/dkw292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Antimicrobial chemotherapy now spans 80 years and four generations. The healthcare epidemiologist has an important role to play in this field. Efforts focus in three areas: (i) minimizing the transmission of antimicrobial-resistant bacteria in healthcare settings (infection control); (ii) optimizing use of currently available antibacterial drugs (antibiotic stewardship); and (iii) recognizing and responding to opportunities for new drug development. For each area, the epidemiologist provides data that address four practical questions-'What is the problem?', 'What should be done?', 'Is it being done?' and 'Is it working?'. A team approach is crucial to acting on the epidemiological data. Examples are presented to illustrate different roles of the epidemiologist, and tools and measures that have been developed to address some problems of current importance. Monitoring of quality, integrity and security of data remains a major focus. The epidemiologist will continue to have a key role in antimicrobial chemotherapy.
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Affiliation(s)
- John E McGowan
- Department of Epidemiology, Rollins School of Public Health of Emory University Department of Medicine (Infectious Diseases), Emory University School of Medicine, 1518 Clifton Rd NE, Atlanta, GA 30322, USA
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48
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Outpatient antibiotic stewardship: Interventions and opportunities. J Am Pharm Assoc (2003) 2017; 57:464-473. [DOI: 10.1016/j.japh.2017.03.014] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 03/07/2017] [Accepted: 03/31/2017] [Indexed: 01/10/2023]
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49
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Roberts RM, Bartoces M, Thompson SE, Hicks LA. Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017; 148:172-178.e1. [PMID: 28126225 PMCID: PMC6814255 DOI: 10.1016/j.adaj.2016.11.020] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Revised: 11/08/2016] [Accepted: 11/27/2016] [Indexed: 12/25/2022]
Abstract
BACKGROUND Dentists prescribe approximately 10% of outpatient antibiotics, but little is known about dentists' antibiotic prescribing patterns. The authors conducted a study to characterize prescribing by dentists according to antibiotic agent and category, patient demographic characteristics, and geographic region in the United States. METHODS The authors identified oral antibiotic prescriptions dispensed during 2013 in the Xponent (QuintilesIMS) database. The authors used the total number of prescriptions and county-level census population denominators to calculate prescribing rates. In addition, the authors analyzed prescribing according to individual agent, drug category, and patient demographic characteristics and the total number of prescriptions calculated for general dentists overall. RESULTS Dentists prescribed 24.5 million courses of antibiotics in 2013, a prescribing rate of 77.5 prescriptions per 1,000 people. Penicillins were the most commonly prescribed antibiotic category. Dentists prescribed most antibiotics for adults older than 19 years. The Northeast census region had the highest prescribing rate per 1,000 people. The District of Columbia had the highest prescribing rate of 99.5 per 1,000 people, and Delaware had the lowest prescribing rate of 50.7 per 1,000 people. CONCLUSIONS Dentists prescribe large quantities of antibiotics in outpatient settings, and there is considerable geographic variability. Additional study is needed to better understand the reasons for this variability and identify areas of possible intervention and improvement. PRACTICAL IMPLICATIONS Continued efforts to combat antibiotic resistance will require all prescribers, including dentists, to examine prescribing behaviors for appropriateness and the effectiveness of guidelines to identify opportunities to optimize antibiotic use.
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Affiliation(s)
- Rebecca M. Roberts
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329
| | - Monina Bartoces
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329
| | - Sydney E. Thompson
- Get Smart: Know When Antibiotics Work Experiential Program, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329
| | - Lauri A. Hicks
- Office of Antibiotic Stewardship, Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, Atlanta, GA 30329
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50
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Frequency of antibiotic associated diarrhea caused by Clostridium difficile among hospitalized patients in intensive care unit, Kerman, Iran. GASTROENTEROLOGY AND HEPATOLOGY FROM BED TO BENCH 2017; 10:229-234. [PMID: 29118940 PMCID: PMC5660274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
AIM This study evaluated the frequency of C. difficile and CDAD in the ICU of Shahid Bahonhar Hospital, Kerman, Iran. BACKGROUND Clostridium difficile (C. difficile) is the most important antibiotic associated diarrhea agent in intensive care unit (ICU) patients. Based on its toxin producing ability, C .difficile is divided to toxigenic and non-toxigenic strains. METHODS A total of 233 diarrheal samples were collected from ICU patients. The samples were cultured on Clostridium difficile medium with 5% defibrinated sheep blood containing cycloserine (500 mg/L), cefoxitin (16 mg/L) and lysozyme (5mg/L). The isolates were confirmed as C. difficile by polymerase chain reaction (PCR) of 16s rRNA gene and the presence of toxins genes (tcdA, tcdB, cdtA and cdtB) was also confirmed. Then, the toxin production of isolates was evaluated using ELISA. RESULTS C. difficile was isolated from 49 (21%) out of 233 samples. The total isolates fell into the A-/B-/CDT- (48.97%), A+/B-/CDT- (28%), A+/B+/CDT- (20.4%) and A+/B+/CDT+ (2%) types. Both types of C.difficile, A-/B-/CDT- and A+/B-/CDT-, which account for 77.5% of all isolates, were unable to produce the toxin (nontoxigenic). On the other hand, A+/B+/CDT+ and A+/B+/CDT- (22.5%), were able to produce toxin or were toxigenic. CONCLUSION The frequency of C. difficile was about 21% and only 22.4% of C. difficile isolates were able to produce toxins. It is expected that C. difficile A+/B+/CDT± are toxigenic and related to C. difficile associated diarrhea (CDAD). Additionally, about 4.7% of hospitalized patients in ICU suffered from CDAD, which is higher than the rates reported from industrialized countries. Notably, 28% of isolates were C. difficile A+/B-/CDT- which only carries tcdA genes without toxin production.
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