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Sapozhnikov J, Albarillo FS, Pulia MS. Optimizing Antimicrobial Stewardship in the Emergency Department. Emerg Med Clin North Am 2024; 42:443-459. [PMID: 38641398 DOI: 10.1016/j.emc.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Antibiotic stewardship is a core component of emergency department (ED) practice and impacts patient safety, clinical outcomes, and public health. The unique characteristics of ED practice, including crowding, time pressure, and diagnostic uncertainty, need to be considered when implementing antibiotic stewardship interventions in this setting. Rapid advances in pathogen detection and host response biomarkers promise to revolutionize the diagnosis of infectious diseases in the ED, but such tests are not yet considered standard of care. Presently, clinical decision support embedded in the electronic health record and pharmacist-led interventions are the most effective ways to improve antibiotic prescribing in the ED.
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Affiliation(s)
- Julia Sapozhnikov
- Medical Science Liaison, Karius Inc, 975 Island Drive, Redwood City, CA 94065, USA
| | - Fritzie S Albarillo
- Department of Medicine, Infectious Diseases Division, Loyola University Medical Center, Loyola University Medical Center is 2160 South First Avenue, Maywood, IL 60153, USA
| | - Michael S Pulia
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, 800 University Bay Drive, Suite 300, Madison, WI 53705, USA.
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Ruiz-Ramos J, Escolà-Vergé L, Monje-López ÁE, Herrera-Mateo S, Rivera A. The Interventions and Challenges of Antimicrobial Stewardship in the Emergency Department. Antibiotics (Basel) 2023; 12:1522. [PMID: 37887223 PMCID: PMC10604141 DOI: 10.3390/antibiotics12101522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 09/25/2023] [Accepted: 10/06/2023] [Indexed: 10/28/2023] Open
Abstract
Over the last decades, we have witnessed a constant increase in infections caused by multi-drug-resistant strains in emergency departments. Despite the demonstrated effectiveness of antimicrobial stewardship programs in antibiotic consumption and minimizing multi-drug-resistant bacterium development, the characteristics of emergency departments pose a challenge to their implementation. The inclusion of rapid diagnostic tests, tracking microbiological results upon discharge, conducting audits with feedback, and implementing multimodal educational interventions have proven to be effective tools for optimizing antibiotic use in these units. Nevertheless, future multicenter studies are essential to determine the best way to proceed and measure outcomes in this scenario.
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Affiliation(s)
- Jesus Ruiz-Ramos
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Laura Escolà-Vergé
- Infectious Diseases Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- CIBERINFEC, ISCIII—CIBER, Instituto de Salud Carlos III, 28029 Madrid, Spain
| | - Álvaro Eloy Monje-López
- Pharmacy Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain;
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
| | - Sergio Herrera-Mateo
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Emergency Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
| | - Alba Rivera
- Sant Pau Institute of Biomedical Research (IIb Sant Pau), 08025 Barcelona, Spain (A.R.)
- Microbiology Department, Hospital Santa Creu i Sant Pau, 08025 Barcelona, Spain
- Genetics and Microbiology Department, Universitat Autònoma de Barcelona, 08025 Barcelona, Spain
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Swingler EA, Song M, Moore SE, Bohn BC, Schulz PS, Junkins AD, Wilde AM. Fluoroquinolone stewardship at a community health system: A decade in review. Antimicrob Steward Healthc Epidemiol 2022; 2:e186. [PMID: 36425222 PMCID: PMC9679733 DOI: 10.1017/ash.2022.326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVE To describe inpatient fluoroquinolone use and susceptibility data over a 10-year period after the implementation of an antimicrobial stewardship program (ASP) led by an infectious diseases pharmacist starting in 2011. DESIGN Retrospective surveillance study. SETTING Large community health system. METHODS Fluoroquinolone use was quantified by days of therapy (DOT) per 1,000 patient days (PD) and reported quarterly. Use data are reported for inpatients from 2016 to 2020. Levofloxacin susceptibility is reported for Pseudomonas aeruginosa and Escherichia coli for inpatients from 2011 to 2020 at a 4 adult-hospital health system. RESULTS Inpatient fluoroquinolone use decreased by 74% over a 5-year period, with an average decrease of 3.45 DOT per 1,000 PD per quarter (P < .001). Over a 10-year period, inpatient levofloxacin susceptibility increased by 57% for P. aeruginosa and by 15% for E. coli. P. aeruginosa susceptibility to levofloxacin increased by an average of 2.73% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = -0.99 (P = .002). E. coli susceptibility to levofloxacin increased by an average of 1.33% per year (P < .001) and had a strong negative correlation with fluoroquinolone use, r = -0.95 (P = .015). CONCLUSIONS A substantial decrease in fluoroquinolone use and increase in P. aeruginosa and E. coli levofloxacin susceptibility was observed after implementation of an antimicrobial stewardship program. These results demonstrate the value of stewardship services and highlight the effectiveness of an infectious diseases pharmacist led antimicrobial stewardship program.
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Affiliation(s)
- Elena A. Swingler
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
| | - Matthew Song
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
| | - Sarah E. Moore
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
| | - Brian C. Bohn
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, Missouri
| | - Paul S. Schulz
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
| | - Alan D. Junkins
- Department of Microbiology, Norton Healthcare, Louisville, Kentucky
| | - Ashley M. Wilde
- Norton Infectious Diseases Institute, Norton Healthcare, Louisville, Kentucky
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Humphrey M, MacDonald G, Neville H, Helwig M, Ramsey T, MacKinnon H, Sketris I, Johnston L, Black EK. A Systematic Review of Antimicrobial Stewardship Interventions to Improve Management of Bacteriuria in Hospitalized Adults. Ann Pharmacother 2022:10600280221134539. [DOI: 10.1177/10600280221134539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Objective: To determine whether implementation of antimicrobial stewardship (AMS) interventions improve management of bacteriuria in hospitalized adults. Data Sources: EMBASE, MEDLINE, CINAHL, and Clinical Trials Registries via Cochrane CENTRAL were searched from inception through May 2021. Reference lists of included studies were searched, and Scopus was used to retrieve articles that cited included references. Study Selection and Data Extraction: Randomized and nonrandomized trials, controlled before-after studies, interrupted time-series studies, and repeated measures studies evaluating AMS interventions for hospitalized adult inpatients with bacteriuria were included. Risk of bias was assessed independently by 3 team members and compared. Results were summarized descriptively. Data Synthesis: The search yielded 5509 articles, of which 13 met inclusion criteria. Most common interventions included education (N = 8) and audit and feedback (N = 5) alone or in combination with other interventions. Where assessed, resource and antimicrobial use primarily decreased and appropriateness of antimicrobial use improved; however, impact on guideline adherence was variable. All studies were rated as having unclear or serious risk of bias. This review summarizes and assesses the quality of evidence for AMS interventions to improve the management of bacteriuria. Results provide guidance to both AMS teams and researchers aiming to develop and/or evaluate AMS interventions for management of bacteriuria. Conclusions: This review demonstrated benefit of AMS interventions on management of bacteriuria. However, most studies had some risk of bias, and an overall effect across studies is unclear due to heterogeneity in outcome measures.
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Affiliation(s)
- Mari Humphrey
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Gemma MacDonald
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Heather Neville
- Department of Pharmacy, Nova Scotia Health, Halifax, NS, Canada
| | - Melissa Helwig
- W.K. Kellogg Health Sciences Library, Dalhousie University, Halifax, NS, Canada
| | - Tasha Ramsey
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
- Department of Pharmacy, Nova Scotia Health, Halifax, NS, Canada
- Division of Infectious Diseases, Nova Scotia Health, Halifax, NS, Canada
| | - Holly MacKinnon
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Ingrid Sketris
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
| | - Lynn Johnston
- Division of Infectious Diseases, Nova Scotia Health, Halifax, NS, Canada
- Faculty of Medicine, Dalhousie University, Halifax, NS, Canada
| | - Emily K. Black
- College of Pharmacy, Dalhousie University, Halifax, NS, Canada
- Department of Pharmacy, IWK Health, Halifax, NS, Canada
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Tandan M, Thapa P, Maharjan P, Bhandari B. Impact of Antimicrobial Stewardship Program on Antimicrobial Resistant and Prescribing in Nursing Home: A Systematic Review and Meta-analysis. J Glob Antimicrob Resist 2022; 29:74-87. [DOI: 10.1016/j.jgar.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Revised: 01/25/2022] [Accepted: 02/06/2022] [Indexed: 11/29/2022] Open
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Shirazi OU, Ab Rahman NS, Zin CS. An overview of the hospitals’ antimicrobial stewardship programs implemented to improve antibiotics’ utilization, cost and resistance patterns. JoP 2022. [DOI: 10.31436/jop.v2i1.76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Introduction: The high reliance of the physicians and surgeons on the antibiotics since their discovery has led to an irrational antibiotic utilization which not only has raised the incidence of antimicrobial resistance (AMR) but also increased the cost of treatment with antibiotics as high use of antibiotics has been found related to the occurrence of certain nosocomial infections which need extra antibiotic courses to be cured. In order to overcome these antibiotic utilization related problems an antimicrobial stewardship (AMS) program being the set of various persuasive, restrictive and structural interventions is considered an effective tool to rationalize the in-patient antimicrobial utilization worldwide.
Method: The focus of this review is on the interventions that are being implemented during the in-patient AMS programs and have been described effective in controlling the antibiotic utilization, their cost of treatment and an overall infection control. The literature containing the information about various AMS interventions effecting the utilization and cost patterns along with the impact on AMR was searched in various databases such as PubMed, Google Scholar, Science Direct, Ovid (Medline) and Scopus. The categorical sorting of the published data is based on various AMS interventions such as the guideline development, formulary restriction (pre-authorization), educative interventions, clinical pathway development and prospective (post prescription) audit. Considering the objectives of the study such as the goal to curb overutilization of antibiotics, control of their cost of treatment for in-patients and infection control the sorted literature is presented in three different tables describing the AMS impact on the said outcomes.
Results: The post AMS changes in utilization patterns are described as fall of antibiotics defined daily doses (DDD) and days of therapy (DOT) which resulted in the reduction of the cost of treatment with antibiotics. The reduction of the cost of treatment with antibiotics also resulted due to the AMS impact on the control of various nosocomial and multi-drug resistant (MDR) infections.
Conclusion: It has been concluded that the AMS program if implemented under the supervision of an expert AMS team mainly comprising of an infectious disease (ID) physician, clinical pharmacists and microbiologists with considerable support by the hospital authorities could be a highly efficient tool of the pharmacovigilance for rationalizing the in-patient antimicrobial practice.
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Harper A, Kepner S. Urinary Tract Infections in Pennsylvania Long-Term Care Facilities. PatientSaf 2021. [DOI: 10.33940/data/2021.12.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Urinary tract infections (UTIs) are common healthcare-associated infections (HAIs) in older adults that live in long-term care (LTC) facilities. A query of the Pennsylvania Patient Safety Reporting System (PA-PSRS) found that symptomatic UTI (SUTI) and catheter-associated UTI (CAUTI) rates increased from 2016 and peaked in the second quarter of 2020. Although the number of urinary catheter days reported by LTC facilities has trended downward from 2016 to the beginning of 2020, the urinary catheter utilization rate increased slightly in the second quarter of 2020. We also examined various epidemiological factors. An average of 47.6% of SUTIs and 32.3% of CAUTIs were associated with E. coli from 2016 through 2020. However, the percentage of CAUTIs associated with E. coli decreased while the percentage of CAUTIs associated with organisms of the tribe Proteeae (Proteus, Providencia, and Morganella genera) increased from 2016 through 2020. Furthermore, the percentage of CAUTIs associated with carbapenem-resistant Enterobacterales (CRE) and organisms producing extended-spectrum beta-lactamases (ESBL) also increased, while the percentage of CAUTIs associated with vancomycin-resistant Enterococci (VRE) decreased from 2016 through 2020. An average of 38.5% of SUTIs and 41.5% of CAUTIs were reported to be treated with fluoroquinolones from 2016 through 2020. However, the percentage of both SUTIs and CAUTIs treated with fluoroquinolones decreased from 2016 through 2020, while an increasing percentage of both SUTIs and CAUTIs was reported to have been treated with cephalosporins and carbapenems from 2016 through 2020. Thus, to further promote resident safety, we use these epidemiological trends to better understand current risks for residents and to further guide development of best practices for prevention, identification, and treatment of UTIs as well as to further advance antibiotic stewardship practices.
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Pédeboscq S, Issa N, Lahouati M, Labadie A, Pereyre S, Camou F. Impact of a 5-year antimicrobial stewardship program focusing on fluoroquinolone prescriptions. Int J Pharm Pract 2021; 29:616-621. [PMID: 34355739 DOI: 10.1093/ijpp/riab047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 07/02/2021] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Within the context of the wide use of fluoroquinolones (FQs) and the emergence of multidrug-resistant bacteria, French recommendations concerning the appropriate use of systemic FQs in adults were published in 2015. This study assessed the impact of antibiotic stewardship intervention on the use of FQs over a 5-year period. METHODS Five annual audits were performed to evaluate FQ prescriptions. Following the baseline audit, a campaign of appropriate antibiotic use was initiated with courses on antibiotics including FQs. All audits included quantitative and qualitative evaluations to calculate an index of therapeutic adequacy (ITA) with six criteria: indication, molecule type, dosage, duration, route of administration and association. These audits were performed annually from 2015 to 2019. KEY FINDINGS The number of prescriptions decreased substantially from 90 in 2015 to 17 in 2019. This reduction was consistent with consumption data, such that the defined daily dose for 1000 bed days diminished from 67 in 2015 to 42 in 2019. Between 2015 and 2016, the ITA decreased significantly from 3.27 to 1.79 (P = 0.001), corresponding to an improvement in prescription quality. The ITA stabilised between 2016 and 2019. Moreover, improvements were observed in the proportion of entirely conforming prescriptions, conformity of indications, choice of molecule type among FQs and proportion of prescriptions with non-conforming treatment durations. CONCLUSIONS Between 2015 and 2019, we observed quantitative and qualitative improvements in FQ prescriptions within the hospital. Prescription follow-up through annual audits, combined with training courses, contributed to consistent results.
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Affiliation(s)
- Stéphane Pédeboscq
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Nahema Issa
- Intensive Care and Infectious Disease Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Marin Lahouati
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Aurélie Labadie
- Pharmacy Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
| | - Sabine Pereyre
- Bacteriology Laboratory, University Hospital of Bordeaux, Bordeaux, France
| | - Fabrice Camou
- Intensive Care and Infectious Disease Department, Saint-André Hospital, University Hospital of Bordeaux, Bordeaux, France
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Jones KA, Onwubiko UN, Kubes J, Albrecht B, Paciullo K, Howard-Anderson J, Suchindran S, Trible R, Jacob JT, Yi SH, Goodenough D, Fridkin SK, Sexton ME, Wiley Z. Reductions in inpatient fluoroquinolone use and postdischarge Clostridioides difficile infection (CDI) from a systemwide antimicrobial stewardship intervention. Antimicrob Steward Healthc Epidemiol 2021; 1:e32. [PMID: 36168449 PMCID: PMC9495417 DOI: 10.1017/ash.2021.197] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 09/09/2021] [Accepted: 09/14/2021] [Indexed: 12/12/2022]
Abstract
Objective To determine the impact of an inpatient stewardship intervention targeting fluoroquinolone use on inpatient and postdischarge Clostridioides difficile infection (CDI). Design We used an interrupted time series study design to evaluate the rate of hospital-onset CDI (HO-CDI), postdischarge CDI (PD-CDI) within 12 weeks, and inpatient fluoroquinolone use from 2 years prior to 1 year after a stewardship intervention. Setting An academic healthcare system with 4 hospitals. Patients All inpatients hospitalized between January 2017 and September 2020, excluding those discharged from locations caring for oncology, bone marrow transplant, or solid-organ transplant patients. Intervention Introduction of electronic order sets designed to reduce inpatient fluoroquinolone prescribing. Results Among 163,117 admissions, there were 683 cases of HO-CDI and 1,104 cases of PD-CDI. In the context of a 2% month-to-month decline starting in the preintervention period (P < .01), we observed a reduction in fluoroquinolone days of therapy per 1,000 patient days of 21% after the intervention (level change, P < .05). HO-CDI rates were stable throughout the study period. In contrast, we also detected a change in the trend of PD-CDI rates from a stable monthly rate in the preintervention period to a monthly decrease of 2.5% in the postintervention period (P < .01). Conclusions Our systemwide intervention reduced inpatient fluoroquinolone use immediately, but not HO-CDI. However, a downward trend in PD-CDI occurred. Relying on outcome measures limited to the inpatient setting may not reflect the full impact of inpatient stewardship efforts.
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Affiliation(s)
| | - Udodirim N. Onwubiko
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | - Jessica Howard-Anderson
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Sujit Suchindran
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ronald Trible
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Jesse T. Jacob
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Sarah H. Yi
- Division of Healthcare Quality Promotion, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Dana Goodenough
- Georgia Emerging Infections Program, Atlanta, Georgia
- Foundation for Atlanta Veterans’ Education & Research, Decatur, Georgia
- Atlanta Veterans’ Affairs Medical Center, Decatur, Georgia
| | - Scott K. Fridkin
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
- Georgia Emerging Infections Program, Atlanta, Georgia
| | - Mary Elizabeth Sexton
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Zanthia Wiley
- Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Piraux A, Faure S, Naber KG, Alidjanov JF, Ramond-Roquin A. Changes in the management of urinary tract infections in women: impact of the new recommendations on antibiotic prescribing behavior in France, between 2014 and 2019. BMC Health Serv Res 2021; 21:612. [PMID: 34182991 PMCID: PMC8240268 DOI: 10.1186/s12913-021-06653-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 06/14/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Urinary tract infections (UTIs) are among the most common infections that require antibiotic therapy. In December 2015, new guidelines for UTI management were published in France with the aim of reducing antibiotic misuse and the risk of antimicrobial resistance. OBJECTIVES To analyze changes in antibiotic prescribing behavior for acute uncomplicated UTI in women in France from 2014 to 2019. METHODS Retrospective study using data extracted from the medico-administrative database 'OpenMedic' that is linked to the French National Health Data System and collects data on the reimbursement of prescribed drugs. The analyses focused on the number of boxes of antibiotics delivered by community pharmacies, the molecule class, and the prescriber's specialty. RESULTS Overall, antibiotic dispensing by community pharmacies increased by 2% between 2014 and 2019, but with differences in function of the antibiotic class. The use of antibiotics recommended as first-line and second-line treatment increased (+ 41% for fosfomycin and + 7430% for pivmecillinam). Conversely, the dispensing of lomefloxacin and norfloxacin decreased by 80%, and that of ciprofloxacin by 26%. Some antibiotics were mostly prescribed by general practitioners (lomefloxacin, pivmecillinam) and others by secondary care physicians (ofloxacin). Dispensing increased for antibiotics prescribed by secondary care physicians (+ 13% between 2014 and 2019) and decreased for antibiotics prescribed by GPs (- 2% for the same period). CONCLUSION These data suggest that the new recommendations are followed, as indicated by the increased prescription of fosfomycin and pivmecillinam and decreased prescription of fluoroquinolones. However, the efficient transmission and implementation of new recommendations by practitioners requires time, means and dedicated tools.
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Affiliation(s)
- Arthur Piraux
- Univ Angers, Inserm, CNRS, MINT, SFR ICAT, 16 boulevard Daviers, F-49000, Angers, France.
| | - Sébastien Faure
- Univ Angers, Inserm, CNRS, MINT, SFR ICAT, 16 boulevard Daviers, F-49000, Angers, France
| | - Kurt G Naber
- Department of Urology, Technical University of Munich, Munich, Germany
| | - Jakhongir F Alidjanov
- Department of Urology, Pediatric Urology and Andrology, Justus-Liebig University of Giessen, Giessen, Germany
| | - Aline Ramond-Roquin
- Faculté de Santé, Département de Médecine Générale, Univ Angers, F-49000, Angers, France
- Univ Angers, Univ Rennes, EHESP1, Inserm, IRSET-ESTER, SFR ICAT, F-49000, Angers, France
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Smoke SM, Plotkin S, Patel N, Hilden P. Save the Quinolones! Impact of a Non-Restrictive Fluoroquinolone Reduction Initiative on Antibiotic Use and Resistance at an Urban Teaching Hospital. J Pharm Pract 2021; 35:707-710. [PMID: 33759616 DOI: 10.1177/08971900211003447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Many antibiotic stewardship programs have sought to reduce fluoroquinolone use due to their association with a myriad of negative consequences. In hospital settings with fewer resources, initiatives that are less labor intensive may offer a more feasible approach to addressing fluoroquinolone use and improving patient care. OBJECTIVE This study assessed the impact of a non-restrictive fluoroquinolone reduction initiative on antibiotic use and resistance. METHODS This was a retrospective pre- and post-interventional ecological study conducted from 2016 to 2017. The fluoroquinolone reduction initiative consisted of education on risks and alternatives. Buttons promoting "Save the Quinolones" were also worn to increase visibility. Outcome measures were the rate of fluoroquinolone use and antibiotic resistance in Staphylococcus aureus, Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae, and Pseudomonas aeruginosa before and after the intervention. RESULTS Overall, fluoroquinolone use decreased throughout the study, but there was a significantly greater rate of decrease in the post-intervention period (monthly decrease of 3.3% (1.3, 5.1) v. 7.4% (5, 9.8) p = 0.043). S. aureus susceptibility to oxacillin increased from 47.2% to 55.2% (difference 8.0, 95%CI 1.2 to 14.7). P. aeruginosa susceptibility to levofloxacin increased from 60% to 70.7% (difference 10.7, 95%CI 0.8 to 20.6). No differences in susceptibility rates of E. coli, P. mirabilis or K. pneumoniae were detected. CONCLUSION This non-restrictive fluoroquinolone reduction initiative led to a significant decrease in fluoroquinolone use that was associated with decreased antibiotic resistance in S. aureus and P. aeruginosa.
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Affiliation(s)
- Steven M Smoke
- Pharmacy Department, Saint Barnabas Medical Center, Livingston, NJ, USA
| | - Slava Plotkin
- Pharmacy Department, Jersey City Medical Center, Jersey City, NJ, USA
| | - Neeki Patel
- Pharmacy Department, Jersey City Medical Center, Jersey City, NJ, USA
| | - Patrick Hilden
- Biostatistics Department, Saint Barnabas Medical Center, Livingston, NJ, USA
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McFarland LV, Johnson SB, Evans CT. Perils and pitfalls of probiotic quasi-experimental studies for primary prevention of Clostridioides difficile infection: A review of the evidence. Am J Infect Control 2021; 49:375-384. [PMID: 32791261 DOI: 10.1016/j.ajic.2020.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Primary prevention of Clostridioides (Clostridium) difficile infections (CDI) is an important but challenging infection control goal for hospitals and health care facilities. Enhanced infection control protocols have reduced CDI rates, but the problem persists and administration of probiotics to patients at risk could be very useful if shown to be safe and effective. Randomized controlled trials are largely impractical for primary prevention CDI trials due to large required study sizes and quasi-experimental studies are becoming more frequent as a method to assess this problem. OBJECTIVE Our goal is to review the published quasi-experimental studies adding probiotics to their infection control protocols to reduce CDI and determine the strengths and limitations for this type of study design. METHODS The literature was searched using PubMed, Google Scholar, Medline and Cochrane Databases and gastrointestinal meeting abstracts from January 2000 to January 2020 for quasi-experimental intervention studies testing various probiotics for the primary prevention of CDI. RESULTS We found 28 studies with 7 different types of probiotics (10 studies implementing a hospital-wide intervention, 6 studies targeting 1-3 wards, and 12 studies on either sustainability, cost-effectiveness or subgroup analysis). Some probiotics demonstrated a significant reduction in CDI rates; all four of the probiotic types given only on specific wards and 3 of the 4 probiotics given facility-wide. However, this type of study design was influenced by numerous factors which must be carefully accounted for in the analysis. CONCLUSIONS Some probiotics may be an effective addition to infection control protocols to prevent C. difficile infections, but careful study design considerations are needed.
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Abstract
BACKGROUND AND OBJECTIVES Antibiotic allergy labels are common and are frequently inaccurate. Previous studies among adults demonstrate that β-lactam allergy labels may lead to adverse outcomes, including prescription of broader-spectrum antibiotics, increased costs, and increased lengths of stay, among others. However, data among pediatric patients are lacking, especially in the United States. In this study, we sought to determine the impact of β-lactam allergy labels in hospitalized children with regards to clinical and economic outcomes. METHOD This retrospective cohort study included pediatric patients 30 days to 17 years old, hospitalized at Intermountain Healthcare facilities from 2007 to 2017, who received ≥1 dose of an antibiotic during their admission. Patients with β-lactam allergies were matched to nonallergic patients based on age, sex, clinical service line, admission date, academic children's hospital or other hospital admission, and the presence of chronic, comorbid conditions. Outcomes included receipt of broader-spectrum antibiotics, clinical outcomes including length of stay and readmission, and antibiotic and hospitalization costs. RESULTS In total, 38,906 patients were identified. The prevalence of antibiotic allergy increased from 0.9% among those < 1 year peaked at 10.6% by age 17. Patients with β-lactam allergy received broader-spectrum antibiotics and experienced higher antibiotic costs than nonallergic controls. However, there were no differences in the length of stay, readmission rates, or total number of days of antibiotics between allergic and nonallergic patients. CONCLUSIONS Hospitalized pediatric patients with β-lactam allergy labels receive broader-spectrum antibiotics and experience increased antibiotic costs. This represents an important opportunity for allergy delabeling and antibiotic stewardship.
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Affiliation(s)
- Trahern W Jones
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Nora Fino
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Jared Olson
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
- Department of Pharmacy, Primary Children's Hospital, Salt Lake City, Utah
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah, Salt Lake City, Utah
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14
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Hecker MT, Son AH, Alhmidi H, Wilson BM, Wiest PM, Donskey CJ. Efficacy of a stewardship intervention focused on reducing unnecessary use of non- Clostridioides difficile antibiotics in patients with Clostridioides difficile infection. Infect Control Hosp Epidemiol 2020; 41:216-8. [PMID: 31843033 DOI: 10.1017/ice.2019.346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In a tertiary-care hospital and affiliated long-term care facility, a stewardship intervention focused on patients with Clostridioides difficile infection (CDI) was associated with a significant reduction in unnecessary non-CDI antibiotic therapy. However, there was no significant reduction in total non-CDI therapy or in the frequency of CDI recurrence.
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15
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File TM, Jump RLP, Goff DA. The Role of Antibiotic Stewardship and Telemedicine in the Management of Multidrug-Resistant Infections. Infect Dis Clin North Am 2020; 34:903-920. [PMID: 33131574 DOI: 10.1016/j.idc.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article summarizes the literature describing how antimicrobial stewardship and telemedicine interventions affect antimicrobial resistance. Discussion includes why we need stewardship, how to collaborate with team members, and the evidence of stewardship's and telemedicine's impact on resistance.
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Affiliation(s)
- Thomas M File
- Infectious Disease Division, Antimicrobial Stewardship Program, Summa Health, 75 Arch Street Suite 506, Akron, OH 44304, USA; Internal Medicine, Infectious Disease Section, Northeast Ohio Medical University (NEOMED), Rootstown, OH, USA.
| | - Robin L P Jump
- Department of Medicine, Case Western Reserve University, Cleveland, OH, USA; Geriatric Research, Education and Clinical Center (GRECC), VA Northeast Ohio Healthcare System, 10701 East Boulevard, 111C(O), Cleveland, OH 44016, USA
| | - Debra A Goff
- Department of Pharmacy, College of Pharmacy, The Ohio State University Wexner Medical Center, 368 Doan Hall, Columbus, OH 43210, USA
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16
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Shirazi OU, Ab Rahman NS, Zin CS. A Narrative Review of Antimicrobial Stewardship Interventions within In-patient Settings and Resultant Patient Outcomes. J Pharm Bioallied Sci 2020; 12:369-380. [PMID: 33679082 PMCID: PMC7909060 DOI: 10.4103/jpbs.jpbs_311_19] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 05/18/2020] [Accepted: 06/22/2020] [Indexed: 12/25/2022] Open
Abstract
The overuse of antibiotics has led to various healthcare problems such as the emergence of resistance in infectious microbes and mortality due to antibiotic resistant healthcare associated infections (HAIs). An antimicrobial stewardship (AMS) program is the set of interventions used worldwide to enhance the rational use of antibiotics especially for the hospitalized patients. This review aimed to describe the characteristics of the implemented AMS programs in various hospitals of the world mainly focusing on the interventions and patients outcomes. The literature about AMS program was searched through various databases such as PubMed, Google Scholar, Science Direct, Cochran Library, Ovid (Medline), Web of Science and Scopus. In this review the literature pertaining to the AMS programs for hospitalized patients is sorted on the basis of various interventions that are categorized as formulary restriction (pre-authorization), guideline development, clinical pathway development, educative interventions and prospective audit. Moreover a clear emphasis is laid on the patient outcomes obtained as a result of these interventions namely the infection control, drop in readmission rate, mortality control, resistance control and the control of an overall cost of antibiotic treatment obtained mainly by curbing the overuse of antibiotics within the hospital wards. AMS program is an efficient strategy of pharmacovigilance to rationalize the antimicrobial practice for hospitalized patients as it prevents the misuse of antibiotics, which ultimately retards the health threatening effects of various antibiotics.
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Affiliation(s)
- Ovais Ullah Shirazi
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Norny Syafinaz Ab Rahman
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia.,Big Data Research in Drug Utilization Research Group, Kulliyyah of Pharmacy, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
| | - Che Suraya Zin
- Department of Pharmacy Practice, Kulliyyah of Pharmacy, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia.,Big Data Research in Drug Utilization Research Group, Kulliyyah of Pharmacy, International Islamic University Malaysia, 25200 Kuantan, Pahang, Malaysia
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17
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Silva SY, Wilson BM, Redmond SN, Donskey CJ. Inpatient fluoroquinolone use in Veterans' Affairs hospitals is a predictor of Clostridioides difficile infection due to fluoroquinolone-resistant ribotype 027 strains. Infect Control Hosp Epidemiol 2021; 42:57-62. [PMID: 32962774 DOI: 10.1017/ice.2020.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Reduction in the use of fluoroquinolone antibiotics has been associated with reductions in Clostridioides difficile infections (CDIs) due to fluoroquinolone-resistant strains. OBJECTIVE To determine whether facility-level fluoroquinolone use predicts healthcare facility-associated (HCFA) CDI due to fluoroquinolone-resistant 027 strains. METHODS Using a nationwide cohort of hospitalized patients in the Veterans' Affairs Healthcare System, we identified hospitals that categorized >80% of CDI cases as positive or negative for the 027 strain for at least one-quarter of fiscal years 2011-2018. Within these facilities, we used visual summaries and multilevel logistic regression models to assess the association between facility-level fluoroquinolone use and rates of HCFA-CDI due to 027 strains, controlling for time and facility complexity level, and adjusting for correlated outcomes within facilities. RESULTS Between 2011 and 2018, 55 hospitals met criteria for reporting 027 results, including a total of 5,091 HCFA-CDI cases, with 1,017 infections (20.0%) due to 027 strains. Across these facilities, the use of fluoroquinolones decreased by 52% from 2011 to 2018, with concurrent reductions in the overall HCFA-CDI rate and the proportion of HCFA-CDI cases due to the 027 strain of 13% and 55%, respectively. A multilevel logistic model demonstrated a significant effect of facility-level fluoroquinolone use on the proportion of infections in the facility due to the 027 strain, most noticeably in low-complexity facilities. CONCLUSIONS Our findings provide support for interventions to reduce use of fluroquinolones as a control measure for CDI, particularly in settings where fluoroquinolone use is high and fluoroquinolone-resistant strains are common causes of infection.
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18
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19
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Resman F. Antimicrobial stewardship programs; a two-part narrative review of step-wise design and issues of controversy Part I: step-wise design of an antimicrobial stewardship program. Ther Adv Infect Dis 2020; 7:2049936120933187. [PMID: 32612826 PMCID: PMC7307277 DOI: 10.1177/2049936120933187] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Accepted: 05/11/2020] [Indexed: 12/27/2022] Open
Abstract
Regardless of one's opinion of antimicrobial stewardship programs (ASPs), it is hardly possible to work in hospital care and not be exposed to the term or its practical effects. Despite the term being relatively new, the number of publications in the field is vast, including several excellent reviews of general and specific aspects. Work in antimicrobial stewardship is complex, and includes not only aspects of infectious disease and microbiology, but also of epidemiology, genetics, behavioural psychology, systems science, economics and ethics, to name a few. This review aims to take several of these aspects and the scientific evidence of antimicrobial stewardship studies and merge them into two questions: How should we design ASPs based on what we know today? And which are the most essential unanswered questions regarding antimicrobial stewardship on a broader scale? This narrative review is written in two separate parts aiming to provide answers to the two questions. This first part is written as a step-wise approach to designing a stewardship intervention based on the pillars of unmet need, feasibility, scientific evidence and necessary core elements. It is written mainly as a guide to someone new to the field. It is sorted into five distinct steps: (a) focusing on designing aims; (b) assessing performance and local barriers to rational antimicrobial use; (c) deciding on intervention technique; (d) practical, tailored design including core element inclusion; and (e) evaluation and sustainability. The second part, published separately, formulates ten critical questions on controversies in the field of antimicrobial stewardship. It is aimed at clinicians and researchers with stewardship experience and strives to promote discussion, not to provide answers.
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Affiliation(s)
- Fredrik Resman
- Department of Translational Medicine, Clinical
Infection Medicine, Lund University, Rut Lundskogs Gata 3, Plan 6, Malmö, 20502,
Sweden
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20
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Redmond SN, Silva SY, Wilson BM, Cadnum JL, Donskey CJ. Impact of Reduced Fluoroquinolone Use on Clostridioides difficile Infections Resulting From the Fluoroquinolone-Resistant Ribotype 027 Strain in a Veterans Affairs Medical Center. Pathog Immun 2019; 4:251-259. [PMID: 31637329 PMCID: PMC6782113 DOI: 10.20411/pai.v4i2.327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 09/23/2019] [Indexed: 12/18/2022] Open
Abstract
Background Fluoroquinolone restriction has been proposed as a control measure for Clostridioides difficile infection (CDI) outbreaks associated with fluoroquinolone-resistant ribotype 027 strains. However, relatively few reports of fluoroquinolone restriction interventions have evaluated the impact on C. difficile strain types and fluoroquinolone resistance. Methods In a hospital and affiliated long-term care facility (LTCF), antimicrobial stewardship and environmental cleaning interventions were implemented between 2009 and 2018, and C. difficile isolates during this period (~20 per year) were ribotyped and tested for fluoroquinolone resistance by moxifloxacin minimum inhibitory concentrations (MICs). Pearson's correlation coefficient was used to assess the association between use of fluoroquinolones and the percentage of CDI cases due to the 027 strain over time. Results Between 2009 and 2018, prescribing of fluoroquinolones to inpatients decreased by 43%, coinciding with significant reductions in the healthcare-associated CDI rates in the hospital and LTCF and a decline in the percentage of C. difficile isolates that were ribotype 027 from 70% to 10%. Ninety-five percent of ribotype 027 and 6% of non-027 isolates were moxifloxacin resistant. Hospital fluoroquinolone use was strongly correlated with the incidence of hospital-associated CDI (r = 0.79, 95% confidence interval, 0.31-0.95), but LTCF fluoroquinolone use was not correlated with LTCF-associated CDI (r = 0.29, 95% confidence interval, -0.43-0.77). During the study period, there were statistically significant downward trends in the use of penicillins, intravenous vancomycin, carbapenems, and clindamycin. Conclusion Our results provide support for fluoroquinolone restriction as a control measure for CDI outbreaks due to fluoroquinolone-resistant 027 strains, but also highlight the need for randomized trials as factors such as reduction in other antibiotic classes and improved cleaning may also impact CDI rates.
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Affiliation(s)
- Sarah N Redmond
- Case Western Reserve University School of Medicine; Cleveland, Ohio
| | - Sandra Y Silva
- Clinical and Translational Science Program; School of Medicine; Case Western Reserve University; Cleveland, Ohio
| | - Brigid M Wilson
- Geriatric Research, Education, and Clinical Center; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Jennifer L Cadnum
- Research Service; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
| | - Curtis J Donskey
- Case Western Reserve University School of Medicine; Cleveland, Ohio.,Geriatric Research, Education, and Clinical Center; Louis Stokes Cleveland VA Medical Center; Cleveland, Ohio
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