1
|
Lockhart PB, Durkin MJ, Blumenthal KG, Paumier TM, Baddour LM. Evaluation of patients labeled with a penicillin allergy to promote antimicrobial stewardship in dental practice. J Am Dent Assoc 2024:S0002-8177(24)00143-0. [PMID: 38703160 DOI: 10.1016/j.adaj.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/29/2024] [Accepted: 03/11/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Approximately 10% of the US population self-reports a penicillin allergy history or are labeled as penicillin allergic. However, from 90% through 99% of these patients are not allergic on formal evaluation. CASE DESCRIPTION Patients labeled as penicillin allergic receive broader-spectrum and sometimes less-effective antibiotics, thereby contributing to increased treatment failures, antibiotic resistance, and adverse drug reactions. Self-reported penicillin allergy can be eliminated or classified as low-, medium-, or high-risk after a careful review of patient history. This allows these patients to be delabeled; that is, having any reference to their penicillin allergy history or of having an allergy to penicillin eliminated from their health records. PRACTICAL IMPLICATIONS Oral health care professionals are ideally placed to partner in both antibiotic stewardship interventions by means of recognizing pervasive mislabeling and aiding in the process of delabeling.
Collapse
|
2
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| | | |
Collapse
|
3
|
Marks LR, Durkin MJ, Ayres K, Ellis M. Drug preparation, injection-related infections, and harm reduction practices among a national sample of individuals entering treatment for opioid use disorder. Harm Reduct J 2024; 21:16. [PMID: 38243269 PMCID: PMC10799462 DOI: 10.1186/s12954-024-00939-6] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/16/2024] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The rise in injection drug use in the USA has led to an increase in injection site infections. We performed a national survey of people who use drugs to evaluate common drug use preparation, harm reduction practices, and experiences with injection site infections. METHODS A survey was disseminated to members of the Survey of Key Informants' Patients Program from 2021 to 2022 and distributed to patients 18 years or older newly entering one of 68 substance use disorder treatment programs across the USA with a primary diagnosis of an opioid use disorder. Participants were surveyed about practices when preparing and using drugs, along with self-reported infections and drug use complications. RESULTS 1289 participants responded to the survey. Sexually transmitted infections were common, with 37.6% reporting ever having had any sexually transmitted infection. Injection-associated infections had affected 63.4% of participants who had ever used injection drugs. Many respondents reported not seeking professional medical assistance for infection management, including 29% draining abscesses without seeking medical care and 22.8% obtaining antibiotics through non-healthcare sources. Non-sterile injection practices included sharing needles with others who were febrile or ill (18%), using needles previously used to drain wounds/abscesses (9.9%) for subsequent injection drug use, and licking needles (21.2%). CONCLUSION Patients entering treatment for opioid use disorder reported a high burden of infectious diseases. A number of easily-modifiable high risk behaviors for developing injection-related infections were identified. Efforts are needed to disseminate targeted harm reduction education to PWID on how to reduce their risks for injection-related infections.
Collapse
Affiliation(s)
- Laura R Marks
- Division of Infectious Disease, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, USA.
| | - Michael J Durkin
- Division of Infectious Disease, Washington University School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO, USA
| | - Kelly Ayres
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew Ellis
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
4
|
Durkin MJ, Schmitz V, Hsueh K, Troubh Z, Politi MC. Older adults' and caregivers' perceptions about urinary tract infection and asymptomatic bacteriuria guidelines: a qualitative exploration. Antimicrob Steward Healthc Epidemiol 2023; 3:e224. [PMID: 38156231 PMCID: PMC10753467 DOI: 10.1017/ash.2023.498] [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] [Figures] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/23/2023] [Accepted: 10/25/2023] [Indexed: 12/30/2023]
Abstract
Objective To explore older adults' and caregivers' knowledge and perceptions of guidelines for appropriate antibiotics use for bacteria in the urine. Design Semi-structured qualitative interviews. Setting Infectious disease clinics, community senior living facilities, memory care clinics, and general public. Participants Patients 65 years or older diagnosed with a urinary tract infection (UTI) in the past two years, or caregivers of such patients. Methods We conducted interviews between March and July 2023. We developed an interview guide based on the COM-B (capability, opportunity, motivation-behavior) behavior change framework. We thematically analyzed written transcripts of audio-recorded interviews using inductive and deductive coding techniques. Results Thirty participants (21 patients, 9 caregivers) enrolled. Most participants understood UTI symptoms such as pain during urination and frequent urination. However, communication with multiple clinicians, misinformation, and unclear symptoms that overlapped with other health issues clouded their understanding of asymptomatic bacteriuria (ASB) and UTIs. Some participants worried that clinicians would be dismissive of symptoms if they suggested a diagnosis of ASB without prescribing antibiotics. Many participants felt that the benefits of taking antibiotics for ASB outweighed harms, though some mentioned fears of personal antibiotic resistance if taking unnecessary antibiotics. No participants mentioned the public health impact of potential antibiotic resistance. Most participants trusted information from clinicians over brochures or websites but wanted to review information after clinical conversations. Conclusion Clinician-focused interventions to reduce antibiotic use for ASB should also address patient concerns during clinical visits, and provide standardized high-quality educational materials at the end of the visit.
Collapse
Affiliation(s)
- Michael J. Durkin
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Viktoria Schmitz
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Kevin Hsueh
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - Zoe Troubh
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Mary C. Politi
- Division of Public Health Sciences, Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
5
|
Neuner EA, Atkinson A, Ilges D, Krekel T, Ritchie DJ, Bewley AF, Durkin MJ, Hsueh K, Sayood S. Mixed methods evaluation of handshake antimicrobial stewardship on adult inpatient medicine floors. Antimicrob Steward Healthc Epidemiol 2023; 3:e210. [PMID: 38156212 PMCID: PMC10753471 DOI: 10.1017/ash.2023.465] [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] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 12/30/2023]
Abstract
Objective To evaluate the effects of handshake antimicrobial stewardship on medicine floors at a large tertiary care hospital. Design Retrospective observational study. Setting 1,278-bed academic hospital. Patients Adults admitted to non-ICU medicine services. Interventions A handshake stewardship team consisting of an infectious diseases (ID) physician and pharmacist reviewed charts of patients receiving antimicrobials on medicine floors without a formal ID consult. Recommendations were communicated in-person to providers and acceptance rates were examined with descriptive statistics. Additional data regarding program perception among providers were obtained via surveys. Antibiotic usage trends were extracted from National Healthcare Safety Network Antimicrobial Use option data and evaluated using an interrupted time-series analysis pre- and post-intervention. Results The overall acceptance rate of interventions was 80%, the majority being recommendations either to discontinue (37%) or de-escalate therapy (28%). Medical residents and hospitalists rated the intervention favorably with 90% reporting recommendations were helpful all or most of the time. There was a statistically significant decrease in vancomycin (78 vs 70 DOT/1,000 d present (DP), p = 0.002) and meropenem (24 vs 17 DOT/1,000 DP, p = 0.007) usage and a statistically significant increase in amoxicillin-clavulanate usage (11 vs 15 DOT/1,000 DP, p < 0.001). Overall antibiotic usage remained unchanged by the intervention, though pre-intervention there was a nonsignificant overall increasing trend while post-intervention there was a nonsignificant decreasing trend in overall usage. There was no change in in-hospital mortality. Conclusion The addition of handshake stewardship with adult medicine services was favorably viewed by participants and led to shifts in antibiotic usage.
Collapse
Affiliation(s)
| | - Andrew Atkinson
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Dan Ilges
- Department of Pharmacy, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Tamara Krekel
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - David J. Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital, St. Louis, MO, USA
| | - Alice F. Bewley
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Michael J. Durkin
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Kevin Hsueh
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| | - Sena Sayood
- Department of Internal Medicine, Division of Infectious Diseases, Washington University, School of Medicine in St. Louis, St. Louis, MO, USA
| |
Collapse
|
6
|
Schneider-Smith EG, Suda KJ, Lew D, Rowan S, Hanna D, Bach T, Shimpi N, Foraker RE, Durkin MJ. How decisions are made: Antibiotic stewardship in dentistry. Infect Control Hosp Epidemiol 2023; 44:1731-1736. [PMID: 37553682 PMCID: PMC10782556 DOI: 10.1017/ice.2023.173] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
BACKGROUND We performed a preimplementation assessment of workflows, resources, needs, and antibiotic prescribing practices of trainees and practicing dentists to inform the development of an antibiotic-stewardship clinical decision-support tool (CDST) for dentists. METHODS We used a technology implementation framework to conduct the preimplementation assessment via surveys and focus groups of students, residents, and faculty members. Using Likert scales, the survey assessed baseline knowledge and confidence in dental providers' antibiotic prescribing. The focus groups gathered information on existing workflows, resources, and needs for end users for our CDST. RESULTS Of 355 dental providers recruited to take the survey, 213 (60%) responded: 151 students, 27 residents, and 35 faculty. The average confidence in antibiotic prescribing decisions was 3.2 ± 1.0 on a scale of 1 to 5 (ie, moderate). Dental students were less confident about prescribing antibiotics than residents and faculty (P < .01). However, antibiotic prescribing knowledge was no different between dental students, residents, and faculty. The mean likelihood of prescribing an antibiotic when it was not needed was 2.7 ± 0.6 on a scale of 1 to 5 (unlikely to maybe) and was not meaningfully different across subgroups (P = .10). We had 10 participants across 3 focus groups: 7 students, 2 residents, and 1 faculty member. Four major themes emerged, which indicated that dentists: (1) make antibiotic prescribing decisions based on anecdotal experiences; (2) defer to physicians' recommendations; (3) have limited access to evidence-based resources; and (4) want CDST for antibiotic prescribing. CONCLUSIONS Dentists' confidence in antibiotic prescribing increased by training level, but knowledge did not. Trainees and practicing dentists would benefit from a CDST to improve appropriateness of antibiotic prescribing.
Collapse
Affiliation(s)
- Erika G Schneider-Smith
- Division of Medical Education, Washington University School of Medicine, St. Louis, Missouri
| | - Katie J Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System and the University of Pittsburgh, School of Medicine, Division of General Internal Medicine, Pittsburgh, Pennsylvania
| | - Daphne Lew
- Division of Biostatistics, Washington University School of Medicine, St. Louis, Missouri
| | - Susan Rowan
- Division of General Dentistry, University of Illinois College of Dentistry, Chicago, Illinois
| | - Danny Hanna
- Division of General Dentistry, University of Illinois College of Dentistry, Chicago, Illinois
| | - Tracey Bach
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Neel Shimpi
- Center for Clinical Epidemiology and Population Health, Marshfield Clinic Research Institute, Marshfield, Wisconsin
| | - Randi E Foraker
- Division of General Medical Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
7
|
Vogt LC, Reske KA, Park D, Habrock Bach T, Stewart HB, Arter OG, Stoeckel D, Steinkamp HM, Liang SY, Durkin MJ, Kwon JH. Personal protective equipment use among dental healthcare personnel during the coronavirus disease 2019 (COVID-19) pandemic and the impact of an educational video in clinical practice. Infect Control Hosp Epidemiol 2023; 44:1472-1480. [PMID: 36924218 PMCID: PMC10507497 DOI: 10.1017/ice.2023.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/15/2022] [Accepted: 12/20/2022] [Indexed: 03/18/2023]
Abstract
OBJECTIVE Dental healthcare personnel (DHCP) are at high risk of exposure to coronavirus disease 2019 (COVID-19). We sought to identify how DHCP changed their use of personal protective equipment (PPE) as a result of the COVID-19 pandemic, and to pilot an educational video designed to improve knowledge of proper PPE use. DESIGN The study comprised 2 sets of semistructured qualitative interviews. SETTING The study was conducted in 8 dental clinics in a Midwestern metropolitan area. PARTICIPANTS In total, 70 DHCP participated in the first set of interviews; 63 DHCP participated in the second set of interviews. METHODS In September-November 2020 and March-October 2021, we conducted 2 sets of semistructured interviews: (1) PPE use in the dental community during COVID-19, and (2) feedback on the utility of an educational donning and doffing video. RESULTS Overall, 86% of DHCP reported having prior training. DHCP increased the use of PPE during COVID-19, specifically N95 respirators and face shields. DHCP reported real-world challenges to applying infection control methods, often resulting in PPE modification and reuse. DHCP reported double masking and sterilization methods to extend N95 respirator use. Additional challenges to PPE included shortages, comfort or discomfort, and compatibility with specialty dental equipment. DHCP found the educational video helpful and relevant to clinical practice. Fewer than half of DHCP reported exposure to a similar video. CONCLUSIONS DHCP experienced significant challenges related to PPE access and routine use in dental clinics during the COVID-19 pandemic. An educational video improved awareness and uptake of appropriate PPE use among DHCP.
Collapse
Affiliation(s)
- Lucy C. Vogt
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Kimberly A. Reske
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Park
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Tracey Habrock Bach
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Henry B. Stewart
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Olivia G. Arter
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Daniel Stoeckel
- St. Louis University Center for Advanced Dental Education, St. Louis, Missouri
- St. Louis Children’s Hospital, St. Louis, Missouri
| | - Heidi M. Steinkamp
- St. Louis University Center for Advanced Dental Education, St. Louis, Missouri
| | - Stephen Y. Liang
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Michael J. Durkin
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| | - Jennie H. Kwon
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
8
|
Nolan NS, Fracasso Francis SM, Marks LR, Beekmann SE, Polgreen PM, Liang SY, Durkin MJ. Harm Reduction: A Missing Piece to the Holistic Care of Patients Who Inject Drugs. Open Forum Infect Dis 2023; 10:ofad402. [PMID: 37593531 PMCID: PMC10428197 DOI: 10.1093/ofid/ofad402] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 07/24/2023] [Indexed: 08/19/2023] Open
Abstract
Background The rise in injection drug use (IDU) has led to an increase in drug-related infections. Harm reduction is an important strategy for preventing infections among people who inject drugs (PWID). We attempted to evaluate the harm reduction counseling that infectious diseases physicians provide to PWID presenting with infections. Methods An electronic survey was distributed to physician members of the Emerging Infections Network to inquire about practices used when caring for patients with IDU-related infections. Results In total, 534 ID physicians responded to the survey. Of those, 375 (70%) reported routinely caring for PWID. Most respondents report screening for human immunodeficiency virus (HIV) and viral hepatitis (98%) and discussing the risk of these infections (87%); 63% prescribe immunization against viral hepatitis, and 45% discuss HIV preexposure prophylaxis (PrEP). However, 55% of respondents (n = 205) reported not counseling patients on safer injection strategies. Common reasons for not counseling included limited time and a desire to emphasize antibiotic therapy/medical issues (62%), lack of training (55%), and believing that it would be better addressed by other services (47%). Among respondents who reported counseling PWID, most recommended abstinence from IDU (72%), handwashing and skin cleansing before injection (62%), and safe disposal of needles/drug equipment used before admission (54%). Conclusions Almost all ID physicians report screening PWID for HIV and viral hepatitis and discussing the risks of these infections. Despite frequently encountering PWID, fewer than half of ID physicians provide safer injection advice. Opportunities exist to standardize harm reduction education, emphasizing safer injection practices in conjunction with other strategies to prevent infections (eg, HIV PrEP or hepatitis A virus/hepatitis B virus vaccination).
Collapse
Affiliation(s)
- Nathanial S Nolan
- Division of Infectious Disease, VA St Louis Health Care, St Louis, Missouri, USA
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
| | | | - Laura R Marks
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
| | - Susan E Beekmann
- Division of Infectious Disease, Carver College of Medicine, Iowa City, Iowa, USA
| | - Philip M Polgreen
- Division of Infectious Disease, Carver College of Medicine, Iowa City, Iowa, USA
| | - Stephen Y Liang
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
- Department of Emergency Medicine, Washington University School of Medicine, St Louis Missouri, USA
| | - Michael J Durkin
- Division of Infectious Disease, Washington University School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
9
|
Lake JG, Durkin MJ, Polgreen PM, Beekmann SE, Hersh AL, Newland JG. Pediatric infectious disease physician perceptions of antimicrobial stewardship programs. Infect Control Hosp Epidemiol 2023; 44:1155-1158. [PMID: 35938450 PMCID: PMC10369220 DOI: 10.1017/ice.2022.183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 06/23/2022] [Accepted: 06/24/2022] [Indexed: 11/07/2022]
Abstract
Pediatric antimicrobial stewardship programs (ASPs) improve antibiotic use for hospitalized children. Prescriber surveys indicate acceptance of ASPs, but data on infectious diseases (ID) physician opinions of ASPs are lacking. We conducted a survey of pediatric ID physicians, ASP and non-ASP, and their perceptions of ASP practices and outcomes.
Collapse
Affiliation(s)
- Jason G. Lake
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael J. Durkin
- Division of Adult Infectious Diseases, Department of Internal Medicine, Washington University in St Louis, St Louis, Missouri
| | - Philip M. Polgreen
- Department of Epidemiology, College of Public Health, University of Iowa, Iowa City, Iowa
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Susan E. Beekmann
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Adam L. Hersh
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jason G. Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
10
|
Affiliation(s)
- Sena Sayood
- Washington University in St Louis, School of Medicine, St Louis, Missouri
| | - Michael J Durkin
- Washington University in St Louis, School of Medicine, St Louis, Missouri
| |
Collapse
|
11
|
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] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
12
|
Desai S, Shah K, Thwe EE, Modi VA, Durkin MJ. IN-HOSPITAL OUTCOMES AND COMPLICATIONS OF CATHETER ABLATION AND PACEMAKER PLACEMENT IN PATIENTS WITH ATRIAL FIBRILLATION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)00652-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
|
13
|
Wildenthal JA, Atkinson A, Lewis S, Sayood S, Nolan NS, Cabrera NL, Marschall J, Durkin MJ, Marks LR. Outcomes of Partial Oral Antibiotic Treatment for Complicated Staphylococcus aureus Bacteremia in People Who Inject Drugs. Clin Infect Dis 2023; 76:487-496. [PMID: 36052413 PMCID: PMC10169408 DOI: 10.1093/cid/ciac714] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/18/2022] [Accepted: 08/29/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Staphylococcus aureus represents the leading cause of complicated bloodstream infections among persons who inject drugs (PWID). Standard of care (SOC) intravenous (IV) antibiotics result in high rates of treatment success but are not feasible for some PWID. Transition to oral antibiotics may represent an alternative treatment option. METHODS We evaluated all adult patients with a history of injection drug use hospitalized from January 2016 through December 2021 with complicated S. aureus bloodstream infections, including infective endocarditis, epidural abscess, vertebral osteomyelitis, and septic arthritis. Patients were compared by antibiotic treatment (standard of care intravenous [SOC IV] antibiotics, incomplete IV therapy, or transition from initial IV to partial oral) using the primary composite endpoint of death or readmission from microbiologic failure within 90 days of discharge. RESULTS Patients who received oral antibiotics after an incomplete IV antibiotic course were significantly less likely to experience microbiologic failure or death than patients discharged without oral antibiotics (P < .001). There was no significant difference in microbiologic failure rates when comparing patients who were discharged on partial oral antibiotics after receiving at least 10 days of IV antibiotics with SOC regimens (P > .9). CONCLUSIONS Discharge of PWID with partially treated complicated S. aureus bacteremias without oral antibiotics results in high rates of morbidity and should be avoided. For PWID hospitalized with complicated S. aureus bacteremias who have received at least 10 days of effective IV antibiotic therapy after clearance of bacteremia, transition to oral antibiotics with outpatient support represents a potential alternative if the patient does not desire SOC IV antibiotic therapy.
Collapse
Affiliation(s)
- John A Wildenthal
- Medical Scientist Training Program, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
- Department of Computational and Systems Biology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Andrew Atkinson
- Department of Infectious Diseases, Bern University Hospital, Inselspital, University of Bern, Bern, Switzerland
| | - Sophia Lewis
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Sena Sayood
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nicolo L Cabrera
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Jonas Marschall
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
14
|
Choudhary S, Durkin MJ, Stoeckel DC, Steinkamp HM, Thornhill MH, Lockhart PB, Babcock HM, Kwon JH, Liang SY, Biswas P. Comparison of aerosol mitigation strategies and aerosol persistence in dental environments. Infect Control Hosp Epidemiol 2022; 43:1779-1784. [PMID: 35440351 PMCID: PMC10822722 DOI: 10.1017/ice.2022.26] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To determine the impact of various aerosol mitigation interventions and to establish duration of aerosol persistence in a variety of dental clinic configurations. METHODS We performed aerosol measurement studies in endodontic, orthodontic, periodontic, pediatric, and general dentistry clinics. We used an optical aerosol spectrometer and wearable particulate matter sensors to measure real-time aerosol concentration from the vantage point of the dentist during routine care in a variety of clinic configurations (eg, open bay, single room, partitioned operatories). We compared the impact of aerosol mitigation strategies (eg, ventilation and high-volume evacuation (HVE), and prevalence of particulate matter) in the dental clinic environment before, during, and after high-speed drilling, slow-speed drilling, and ultrasonic scaling procedures. RESULTS Conical and ISOVAC HVE were superior to standard-tip evacuation for aerosol-generating procedures. When aerosols were detected in the environment, they were rapidly dispersed within minutes of completing the aerosol-generating procedure. Few aerosols were detected in dental clinics, regardless of configuration, when conical and ISOVAC HVE were used. CONCLUSIONS Dentists should consider using conical or ISOVAC HVE rather than standard-tip evacuators to reduce aerosols generated during routine clinical practice. Furthermore, when such effective aerosol mitigation strategies are employed, dentists need not leave dental chairs fallow between patients because aerosols are rapidly dispersed.
Collapse
Affiliation(s)
- Shruti Choudhary
- Aerosol and Air Quality Research Laboratory, Department of Chemical, Environmental and Material Engineering, University of Miami, Miami, Florida, United States
| | - Michael J. Durkin
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Daniel C. Stoeckel
- St. Louis University Center for Advanced Dental Education, St. Louis University, St. Louis, Missouri, United States
| | - Heidi M. Steinkamp
- St. Louis University Center for Advanced Dental Education, St. Louis University, St. Louis, Missouri, United States
| | - Martin H. Thornhill
- The School of Clinical Dentistry, The University of Sheffield, Sheffield, United Kingdom
- Department of Oral Medicine, Carolinas Medical Center, Atrium Health, North Carolina, United States
| | - Peter B. Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Atrium Health, North Carolina, United States
| | - Hilary M. Babcock
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Jennie H. Kwon
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Stephen Y. Liang
- Division of Infectious Disease, Washington University School of Medicine, St. Louis, Missouri, United States
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, United States
| | - Pratim Biswas
- Aerosol and Air Quality Research Laboratory, Department of Chemical, Environmental and Material Engineering, University of Miami, Miami, Florida, United States
| |
Collapse
|
15
|
Choudhary S, Bach T, Wallace MA, Stoeckel DC, Thornhill MH, Lockhart PB, Kwon JH, Liang SY, Burnham CAD, Biswas P, Steinkamp HM, Durkin MJ. Assessment of infectious diseases risks from dental aerosols in real world settings. Open Forum Infect Dis 2022; 9:ofac617. [DOI: 10.1093/ofid/ofac617] [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] [Received: 10/02/2022] [Accepted: 11/10/2022] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Infectious diseases physicians are leaders in assessing the health risks in a variety of community settings. An understudied area with substantial controversy is the safety of dental aerosols. Previous studies have used in vitro experimental designs and/or indirect measures to evaluate bacteria and viruses from dental surfaces. However, these findings may overestimate the occupational risks of dental aerosols. The purpose of this study was to directly measure dental aerosol composition to assess the health risks for dental healthcare personnel and patients.
Methods
We used a variety of aerosol instruments to capture and measure the bacterial, viral, and inorganic composition of aerosols during a variety of common dental procedures and in a variety of dental office layouts. Equipment was placed in close proximity to dentists during each procedure to best approximate the health risk hazards from the perspective of the DHCP. Devices used to capture aerosols were set at physiologic respiration rates. Oral suction devices were per the discretion of the dentist.
Results
We detected very few bacteria and no viruses in dental aerosols – regardless of office layout. The bacteria identified were most consistent with either environmental or oral microbiota, suggesting a low risk of transmission of viable pathogens from patients to DHCPs. When analyzing restorative procedures involving amalgam removal, we detected inorganic elements consistent with amalgam fillings.
Conclusions
Aerosols generating from dental procedures pose a low health risk for bacterial and likely viral pathogens when common aerosol mitigation interventions, such as suction devices, are employed.
Collapse
Affiliation(s)
- Shruti Choudhary
- Aerosol and Air Quality Research Laboratory, Department of Chemical, Environmental and Material Engineering University of Miami , FL 33146 , USA
| | - Tracey Bach
- Division of Infectious Disease, Washington University School of Medicine , St. Louis, MO 63110 , USA
| | - Meghan A Wallace
- Department of Pathology and Immunology, Washington University School of Medicine , St Louis, MO 63110 , USA
| | - Daniel C Stoeckel
- St. Louis University Center for Advanced Dental Education, St Louis University , MO 63104 , USA
| | - Martin H Thornhill
- The School of Clinical Dentistry, The University of Sheffield , Sheffield, S10 2TN , UK
- Department of Oral Medicine/Oral & Maxillofacial Surgery, Carolinas Medical Center- Atrium Health , Charlotte, NC 28232 , USA
| | - Peter B Lockhart
- Department of Oral Medicine/Oral & Maxillofacial Surgery, Carolinas Medical Center- Atrium Health , Charlotte, NC 28232 , USA
| | - Jennie H Kwon
- Division of Infectious Disease, Washington University School of Medicine , St. Louis, MO 63110 , USA
| | - Stephen Y Liang
- Division of Infectious Disease, Washington University School of Medicine , St. Louis, MO 63110 , USA
- Department of Emergency Medicine, Washington University School of Medicine , St Louis, MO 63110 , USA
| | - Carey-Ann D Burnham
- Department of Pathology and Immunology, Washington University School of Medicine , St Louis, MO 63110 , USA
| | - Pratim Biswas
- Aerosol and Air Quality Research Laboratory, Department of Chemical, Environmental and Material Engineering University of Miami , FL 33146 , USA
| | - Heidi M Steinkamp
- St. Louis University Center for Advanced Dental Education, St Louis University , MO 63104 , USA
- Department of Pediatric Dentistry, University of Iowa College of Dentistry , Iowa City, IA, 52242 , USA
| | - Michael J Durkin
- Division of Infectious Disease, Washington University School of Medicine , St. Louis, MO 63110 , USA
| |
Collapse
|
16
|
Reske KA, Park D, Bach TH, Stewart HB, Vogt LC, Arter OG, Stoeckel D, Steinkamp HM, Liang SY, Durkin MJ, Kwon JH. Assessment of dental health care personnel protocol deviations and self-contamination during personal protective equipment donning and doffing. J Am Dent Assoc 2022; 153:1070-1077.e1. [PMID: 36175202 PMCID: PMC9511115 DOI: 10.1016/j.adaj.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/24/2022] [Accepted: 08/02/2022] [Indexed: 11/25/2022]
Abstract
Background Dental health care personnel (DHCP) may be at increased risk of exposure to severe acute respiratory syndrome coronavirus 2, the virus that causes COVID-19, as well as other clinically important pathogens. Proper use of personal protective equipment (PPE) reduces occupational exposure to pathogens. The authors performed an assessment of PPE donning and doffing practices among DHCP, using a fluorescent marker as a surrogate for pathogen transmission. Methods Participants donned PPE (that is, disposable gown, gloves, face mask, and eye protection) and the fluorescent marker was applied to their palms and abdomen. DHCP then doffed PPE according to their usual practices. The donning and doffing processes were video recorded, areas of fluorescence were noted, and protocol deviations were assessed. Statistical analyses included frequency, type, and descriptions of protocol deviations and factors associated with fluorescence. Results Seventy DHCP were enrolled. The donning and doffing steps with the highest frequency of protocol deviations were hand hygiene (66% of donning and 78% of doffing observations involved a deviation) and disposable gown use (63% of donning and 60% of doffing observations involved a deviation). Fluorescence was detected on 69% of DHCP after doffing, most frequently on hands. An increasing number of protocol deviations was significantly associated with increased risk of fluorescence. DHCP with a gown doffing deviation, excluding doffing out of order, were more likely to have fluorescence detected. Conclusions DHCP self-contamination was common with both donning and doffing PPE. Practical Implications Proper use of PPE is an important component of occupational health.
Collapse
|
17
|
Nolan NS, Gleason E, Marks LR, Habrock-Bach T, Liang SY, Durkin MJ. Experiences Using a Multidisciplinary Model for Treating Injection Drug Use Associated Infections: A Qualitative Study. Front Psychiatry 2022; 13:924672. [PMID: 35800016 PMCID: PMC9253819 DOI: 10.3389/fpsyt.2022.924672] [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] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Accepted: 05/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Over the past two decades, the United States has experienced a dramatic increase in the rate of injection drug use, injection associated infections, and overdose mortality. A hospital-based program for treating opioid use disorder in people who inject drugs presenting with invasive infections was initiated at an academic tertiary care center in 2020. The goal of this program was to improve care outcomes, enhance patient experiences, and facilitate transition from the hospital to longer term addiction care. The purpose of this study was to interview two cohorts of patients, those admitted before vs. after initiation of this program, to understand the program's impact on care from the patient's perspective and explore ways in which the program could be improved. Methods Thirty patients admitted to the hospital with infectious complications of injection drug use were interviewed using a semi-structured format. Interviews were transcribed and coded. Emergent themes were reported. Limited descriptive statistics were reported based on chart review. Results Thirty interviews were completed; 16 participants were part of the program (admitted after program implementation) while 14 were not participants (admitted prior to implementation). Common themes associated with hospitalization included inadequate pain control, access to medications for opioid use disorder (MOUD), loss of freedom, stigma from healthcare personnel, and benefits of having an interprofessional team. Participants in the program were more likely to report adequate pain control and access to MOUD and many cited benefits from receiving care from an interprofessional team. Conclusions Patients with opioid use disorder admitted with injection related infections reported improved experiences when receiving care from an interprofessional team focused on their addiction. However, perceived stigma from healthcare personnel and loss of freedom related to hospitalization were continued barriers to care before and after implementation of this program.
Collapse
Affiliation(s)
- Nathanial S. Nolan
- Department of Medicine, Division of Infectious Diseases, St. Louis School of Medicine, Washington University, St. Louis, MO, United States
| | - Emily Gleason
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Laura R. Marks
- Department of Medicine, Division of Infectious Diseases, St. Louis School of Medicine, Washington University, St. Louis, MO, United States
| | - Tracey Habrock-Bach
- Department of Medicine, Division of Infectious Diseases, St. Louis School of Medicine, Washington University, St. Louis, MO, United States
| | - Stephen Y. Liang
- Department of Medicine, Division of Infectious Diseases, St. Louis School of Medicine, Washington University, St. Louis, MO, United States
- Department of Emergency Medicine, St. Louis School of Medicine, Washington University, St. Louis, MO, United States
| | - Michael J. Durkin
- Department of Medicine, Division of Infectious Diseases, St. Louis School of Medicine, Washington University, St. Louis, MO, United States
| |
Collapse
|
18
|
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: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [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.
Collapse
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
| |
Collapse
|
19
|
Vivo A, Durkin MJ, Kale I, Boyer T, Fitzpatrick MA, Evans CT, Jurasic MM, Gibson G, Suda KJ. Opportunities for penicillin allergy evaluation in dental clinics. Antimicrob Steward Healthc Epidemiol 2022; 2:e58. [PMID: 36483385 PMCID: PMC9726497 DOI: 10.1017/ash.2022.18] [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] [Figures] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 01/11/2022] [Accepted: 01/12/2022] [Indexed: 06/17/2023]
Abstract
OBJECTIVE To evaluate opportunities for assessing penicillin allergies among patients presenting to dental clinics. DESIGN Retrospective cross-sectional study. SETTING VA dental clinics. PATIENTS Adult patients with a documented penicillin allergy who received an antibiotic from a dentist between January 1, 2015, and December 31, 2018, were included. METHODS Chart reviews were completed on random samples of 100 patients who received a noncephalosporin antibiotic and 200 patients who received a cephalosporin. Each allergy was categorized by severity. These categories were used to determine patient eligibility for 3 testing groups based on peer-reviewed algorithms: (1) no testing, (2) skin testing, and (3) oral test-dose challenge. Descriptive and bivariate statistics were used to compare facility and patient demographics first between true penicillin allergy, pseudo penicillin allergy, and missing allergy documentation, and between those who received a cephalosporin and those who did not at the dental visit. RESULTS Overall, 19% lacked documentation of the nature of allergic reaction, 53% were eligible for skin testing, 27% were eligible for an oral test-dose challenge, and 1% were contraindicated from testing. Male patients and African American patients were less likely to receive a cephalosporin. CONCLUSIONS Most penicillin-allergic patients in the VA receiving an antibiotic from a dentist are eligible for penicillin skin testing or an oral penicillin challenge. Further research is needed to understand the role of dentists and dental clinics in assessing penicillin allergies.
Collapse
Affiliation(s)
- Amanda Vivo
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
| | | | - Ibuola Kale
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
| | - Taylor Boyer
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
| | - Margaret A. Fitzpatrick
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
- Loyola University Chicago Stritch School of Medicine, Maywood, Illinois
| | - Charlesnika T. Evans
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr. Veterans’ Affairs (VA) Medical Center, Hines, Illinois
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - M. Marianne Jurasic
- Veterans’ Health Administration Office of Dentistry, Washington, DC
- Boston University Henry M. Goldman School of Dental Medicine, Boston, Massachusetts
- Center for Healthcare Organization and Implementation Research, VA Bedford Healthcare System, Bedford, Massachusetts
| | - Gretchen Gibson
- Veterans’ Health Administration Office of Dentistry, Washington, DC
| | - Katie J. Suda
- Center for Health Equity Research and Promotion, VA Pittsburgh Health Care System, Pittsburgh, Pennsylvania
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
20
|
Shah K, Taha I, Thyagaturu H, Modi VA, Krinock M, Pandya M, Cutitta C, Durkin MJ. IMPACT OF VENTRICULAR ARRHYTHMIA ON IN-HOSPITAL OUTCOMES IN PATIENT WITH SARCOIDOSIS. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)01118-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
|
21
|
Gleason E, Nolan NS, Marks LR, Habrock T, Liang SY, Durkin MJ. Barriers to Care Experienced by Patients Who Inject Drugs During the COVID-19 Pandemic: A Qualitative Analysis. J Addict Med 2022; 16:e133-e136. [PMID: 33840774 PMCID: PMC8497648 DOI: 10.1097/adm.0000000000000853] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/21/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify the barriers to accessing health care and social services faced by people who inject drugs (PWID) during the coronavirus disease 2019 (COVID-19) pandemic. METHODS This report is a sub-analysis of a larger qualitative study. Semi-structured interviews were conducted with PWID admitted to an academic medical center from 2017 to 2020 for an invasive injection-related infection. Standard qualitative analysis techniques, consisting of both inductive and deductive approaches, were used to identify and characterize the effects of COVID-19 on participants. RESULTS Among the 30 PWID interview participants, 14 reported barriers to accessing health and addiction services due to COVID-19. As facilities decreased appointment availability or transitioned to telemedicine, PWID reported being unable to access services. Social distancing led to isolation or loneliness during hospital stays and in the community. Recovery meetings and support groups, critical to addiction recovery, were particularly affected. Other participants reported that uncertainty and fear of contracting the virus generated changes in behavior that led them to avoid seeking services. CONCLUSIONS COVID-19 has disrupted health systems and social services, leading PWID to experience unprecedented barriers to accessing and maintaining health and addiction services in both inpatient and outpatient settings. Opioid use disorder management must be understood as a holistic process, and a multidisciplinary approach to ensuring comprehensive care, even in the midst of this pandemic, is needed.
Collapse
Affiliation(s)
- Emily Gleason
- Department of Medicine, Division of Infectious Diseases, Washington University in St. Louis School of Medicine (EG, NSN, LRM, TH, SYL, MJD); Division of Emergency Medicine, Washington University in St. Louis School of Medicine (SYL)
| | | | | | | | | | | |
Collapse
|
22
|
Lewis S, Liang SY, Schwarz ES, Liss DB, Winograd RP, Nolan NS, Durkin MJ, Marks LR. Patients with serious injection drug use related infections who experience patient directed discharges on oral antibiotics have high rates of antibiotic adherence but require multidisciplinary outpatient support for retention in care. Open Forum Infect Dis 2022; 9:ofab633. [PMID: 35106316 PMCID: PMC8801224 DOI: 10.1093/ofid/ofab633] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/08/2021] [Indexed: 12/04/2022] Open
Abstract
Background Persons who inject drugs (PWID) are frequently admitted for serious injection-related infections (SIRIs). Outcomes and adherence to oral antibiotics for PWID with patient-directed discharge (PDD) remain understudied. Methods We conducted a prospective multicenter bundled quality improvement project of PWID with SIRI at 3 hospitals in Missouri. All PWID with SIRI were offered multidisciplinary care while inpatient, including the option of addiction medicine consultation and medications for opioid use disorder (MOUD). All patients were offered oral antibiotics in the event of a PDD either at discharge or immediately after discharge through an infectious diseases telemedicine clinic. Additional support services included health coaches, a therapist, a case manager, free clinic follow-up, and medications in an outpatient bridge program. Patient demographics, comorbidities, 90-day readmissions, and substance use disorder clinic follow-up were compared between PWID with PDD on oral antibiotics and those who completed intravenous (IV) antibiotics using an as-treated approach. Results Of 166 PWID with SIRI, 61 completed IV antibiotics inpatient (37%), while 105 had a PDD on oral antibiotics (63%). There was no significant difference in 90-day readmission rates between groups (P = .819). For PWID with a PDD on oral antibiotics, 7.6% had documented nonadherence to antibiotics, 67% had documented adherence, and 23% were lost to follow-up. Factors protective against readmission included antibiotic and MOUD adherence, engagement with support team, and clinic follow-up. Conclusions PWID with SIRI who experience a PDD should be provided with oral antibiotics. Multidisciplinary outpatient support services are needed for PWID with PDD on oral antibiotics.
Collapse
Affiliation(s)
- Sophia Lewis
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Evan S Schwarz
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Division of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - David B Liss
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
- Division of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Rachel P Winograd
- Missouri Institute of Mental Health, University of Missouri-St. Louis, MO, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| |
Collapse
|
23
|
Abstract
The opioid overdose epidemic is one of the leading causes of death in adults. Its devastating effects have included not only a burgeoning overdose crisis but also multiple converging infectious diseases epidemics. The use of both opioids and other substances through intravenous (IV) administration places individuals at increased risks of infectious diseases ranging from invasive bacterial and fungal infections to human immunodeficiency virus (HIV) and viral hepatitis. In 2012, there were 530,000 opioid use disorder (OUD)-related hospitalizations in the United States (US), with $700 million in costs associated with OUD-related infections. The scale of the crisis has continued to increase since that time, with hospitalizations for injection drug use-related infective endocarditis (IDU-IE) increasing by as much as 12-fold from 2010 to 2015. Deaths from IDU-IE alone are estimated to result in over 7,260,000 years of potential life lost over the next 10 years. There have been high-profile injection-related HIV outbreaks, and injection drug use (IDU) is now the most common risk factor for hepatitis C virus (HCV). As this epidemic continues to grow, clinicians in all aspects of medical care are increasingly confronted with infectious complications of IDU. This review will describe the pathogenesis, clinical syndromes, epidemiology, and models of treatment for common infectious complications among persons who inject drugs (PWIDs).
Collapse
Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA.
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA; Division of Emergency Medicine, Washington University in St. Louis School of Medicine
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, Campus Box 8051, 4523 Clayton Avenue, St. Louis, MO 63110-1093, USA
| | - Melissa B Weimer
- Program in Addiction Medicine, Department of Medicine, Yale School of Medicine, E.S. Harkness Memorial Building A, 367 Cedar Street, Suite 417A, New Haven, CT 06510, USA
| |
Collapse
|
24
|
Beermann SE, Porcelli BA, Durkin MJ, Marks LR, Raghuraman N, Carter EB, Odibo AO, Kelly JC. The impact of hepatitis C on obstetric outcomes in an opioid use disorder-specific prenatal clinic. Am J Obstet Gynecol 2022. [DOI: 10.1016/j.ajog.2021.11.634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
25
|
Sayood S, Marks LR, Patel R, Nolan NS, Liang SY, Durkin MJ. Low Knowledge of HIV PrEP Within a Midwestern US Cohort of Persons who Inject Drugs. Open Forum Infect Dis 2022; 9:ofab541. [PMID: 34988248 PMCID: PMC8714363 DOI: 10.1093/ofid/ofab541] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 11/02/2021] [Indexed: 11/14/2022] Open
Abstract
We interviewed persons who inject drugs (PWID) to understand perceptions of pre-exposure prophylaxis (PrEP) to prevent HIV infection. Knowledge of PrEP was poor. Patients felt that PrEP was for sexual intercourse rather than injection drug use, and PWID managed on medications for opioid use disorder felt that they had no need for PrEP.
Collapse
Affiliation(s)
- Sena Sayood
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Laura R Marks
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Rupa Patel
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, John T. Milliken Department of Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
26
|
Marks LR, Reno H, Liang SY, Schwarz ES, Liss DB, Jiang L, Nolan NS, Durkin MJ. Value of Packaged Testing for Sexually Transmitted Infections for Persons who Inject Drugs Hospitalized With Serious Injection-Related Infections. Open Forum Infect Dis 2021; 8:ofab489. [PMID: 34926711 PMCID: PMC8675536 DOI: 10.1093/ofid/ofab489] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 09/23/2021] [Indexed: 11/14/2022] Open
Abstract
Background Persons who inject drugs (PWID) are frequently admitted for serious injection-related
infections (SIRIs). PWID are also at risk for sexually transmitted infections (STIs). Methods We conducted a multicenter quality improvement project at 3 hospitals in Missouri. PWID with
SIRI who received an infectious diseases consultation were prospectively identified and placed
into an electronic database as part of a Centers for Disease Control and
Prevention–funded quality improvement project. Baseline data were collected from
8/1/2019 to 1/30/2020. During the intervention period (2/1/2020–2/28/2021), infectious
diseases physicians caring for patients received 2 interventions: (1) email reminders of best
practice screening for HIV, viral hepatitis, and STIs; (2) access to a customized EPIC
SmartPhrase that included checkboxes of orders to include in assessment and plan of
consultation notes. STI screening rates were compared before and after the intervention. We
then calculated odds ratios to evaluate for risk factors for STIs in the cohort. Results Three hundred ninety-four unique patients were included in the cohort. Initial screening
rates were highest for hepatitis C (88%), followed by HIV (86%). The bundled intervention
improved screening rates for all conditions and substantially improved screening rates for
gonorrhea, chlamydia, and syphilis (30% vs 51%, 30% vs 51%, and 39 vs 60%, respectively;
P < .001). Of patients who underwent screening, 16.9% were
positive for at least 1 STI. In general, demographics were not strongly associated with
STIs. Conclusions PWID admitted for SIRI frequently have unrecognized STIs. Our bundled intervention improved
STI screening rates, but additional interventions are needed to optimize screening.
Collapse
Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Hilary Reno
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Evan S Schwarz
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Division of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - David B Liss
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Division of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Linda Jiang
- Division of Medical Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
27
|
Marks LR, Calix JJ, Wildenthal JA, Wallace MA, Sawhney SS, Ransom EM, Durkin MJ, Henderson JP, Burnham CAD, Dantas G. Staphylococcus aureus injection drug use-associated bloodstream infections are propagated by community outbreaks of diverse lineages. Commun Med (Lond) 2021; 1:52. [PMID: 35602233 PMCID: PMC9053277 DOI: 10.1038/s43856-021-00053-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 03/22/2021] [Accepted: 11/05/2021] [Indexed: 12/13/2022] Open
Abstract
Background The ongoing injection drug use (IDU) crisis in the United States has been complicated by an emerging epidemic of Staphylococcus aureus IDU-associated bloodstream infections (IDU-BSI). Methods We performed a case-control study comparing S. aureus IDU-BSI and non-IDU BSI cases identified in a large US Midwestern academic medical center between Jan 1, 2016 and Dec 21, 2019. We obtained the whole-genome sequences of 154 S. aureus IDU-BSI and 91 S. aureus non-IDU BSI cases, which were matched with clinical data. We performed phylogenetic and comparative genomic analyses to investigate clonal expansion of lineages and molecular features characteristic of IDU-BSI isolates. Results Here we show that patients with IDU-BSI experience longer durations of bacteremia and have lower medical therapy completion rates. In phylogenetic analyses, 45/154 and 1/91 contemporaneous IDU-BSI and non-IDU BSI staphylococcal isolates, respectively, group into multiple, unique clonal clusters, revealing that pathogen community transmission distinctively spurs IDU-BSI. Lastly, multiple S. aureus lineages deficient in canonical virulence genes are overrepresented among IDU-BSI, which may contribute to the distinguishable clinical presentation of IDU-BSI cases. Conclusions We identify clonal expansion of multiple S. aureus lineages among IDU-BSI isolates, but not non-IDU BSI isolates, in a community with limited access to needle exchange facilities. In the setting of expanding numbers of staphylococcal IDU-BSI cases consideration should be given to treating IDU-associated invasive staphylococcal infections as a communicable disease.
Collapse
Affiliation(s)
- Laura R. Marks
- grid.4367.60000 0001 2355 7002Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO USA
| | - Juan J. Calix
- grid.4367.60000 0001 2355 7002Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO USA
| | - John A. Wildenthal
- grid.4367.60000 0001 2355 7002Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO USA
| | - Meghan A. Wallace
- grid.4367.60000 0001 2355 7002Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO USA
| | - Sanjam S. Sawhney
- grid.4367.60000 0001 2355 7002The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO USA
| | - Eric M. Ransom
- grid.4367.60000 0001 2355 7002Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO USA
| | - Michael J. Durkin
- grid.4367.60000 0001 2355 7002Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO USA
| | - Jeffrey P. Henderson
- grid.4367.60000 0001 2355 7002Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO USA
| | - Carey-Ann D. Burnham
- grid.4367.60000 0001 2355 7002Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO USA
| | - Gautam Dantas
- grid.4367.60000 0001 2355 7002The Edison Family Center for Genome Sciences and Systems Biology, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Pathology and Immunology, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Molecular Microbiology, Washington University School of Medicine, St. Louis, MO USA ,grid.4367.60000 0001 2355 7002Department of Biomedical Engineering, Washington University in St. Louis, St. Louis, MO USA
| |
Collapse
|
28
|
Butler AM, Durkin MJ, Keller MR, Ma Y, Powderly WG, Olsen MA. Association of Adverse Events with Antibiotic Treatment for Urinary Tract Infection. Clin Infect Dis 2021; 74:1408-1418. [PMID: 34279560 DOI: 10.1093/cid/ciab637] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Little is known about the relative harms of different antibiotic regimens prescribed to treat uncomplicated urinary tract infection (UTI). We sought to compare the risk of adverse events associated with commonly-used oral antibiotic regimens for the outpatient treatment of uncomplicated UTI. METHODS We identified 1,169,033 otherwise healthy, non-pregnant women aged 18-44 years with uncomplicated UTI who initiated an oral antibiotic with activity against common uropathogens from July 1, 2006 to September 30, 2015. We used propensity score-weighted Kaplan-Meier methods and Cox proportional hazards regression models to estimate the association between antibiotic agent and adverse events. RESULTS Of two first-line agents, TMP/SMX (versus nitrofurantoin) was associated with higher risk of several adverse drug events including hypersensitivity reaction (hazard ratio [HR] 2.62, 95% CI 2.30-2.98), acute renal failure (HR 2.56, 95% CI 1.55-4.25), skin rash (HR 2.42, 95% CI 2.13-2.75), urticaria (HR 1.37, 95% CI 1.19-1.57), abdominal pain (HR 1.14, 95% CI 1.09-1.19), and nausea / vomiting (HR 1.18, 95% CI 1.10-1.28), but similar risk of potential microbiome-related adverse events. Compared to nitrofurantoin, non-first-line agents were associated with higher risk of several adverse drug events and potential microbiome-related adverse events including non-C. difficile diarrhea, C. difficile infection, vaginitis / vulvovaginal candidiasis, and pneumonia. Treatment duration modified the risk of potential microbiome-related adverse events. CONCLUSIONS The risks of adverse drug events and potential microbiome-related events differ widely by antibiotic agent and duration. These findings underscore the utility of using real-world data to fill evidentiary gaps related to antibiotic safety.
Collapse
Affiliation(s)
- 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
| | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Matthew R Keller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Yinjiao Ma
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - William G Powderly
- 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.,Department of Surgery, Division of Public Health Sciences, Washington University School of Medicine, St. Louis, MO, USA
| |
Collapse
|
29
|
Sayood SJ, Botros M, Suda KJ, Foraker R, Durkin MJ. Attitudes toward using clinical decision support in community pharmacies to promote antibiotic stewardship. J Am Pharm Assoc (2003) 2021; 61:565-571. [PMID: 33962894 DOI: 10.1016/j.japh.2021.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Revised: 04/04/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Outpatient antibiotic prescriptions drive antibiotic overuse in humans, and the Centers for Disease Control and Prevention has identified community pharmacies as potential partners in outpatient stewardship efforts. Clinical decision support (CDS) tools can potentially be used at community pharmacies to aid in outpatient stewardship efforts. OBJECTIVES We sought to determine community pharmacist attitudes toward using a computerized CDS tool to evaluate and manage common complaints and thus promote appropriate antibiotic prescribing. METHODS We conducted in-depth semistructured interviews of community pharmacists to determine attitudes toward using CDS tools in their practice and identify potential barriers in implementation. Thematic analysis was used to identify common themes and subthemes in the pharmacist responses. RESULTS We interviewed 21 pharmacists and identified 5 themes and 14 subthemes in our interviews. The pharmacists reported that patients frequently presented with complaints of acute infections and that they (the pharmacists) were universally supportive of a CDS intervention that would allow them to assess such patients and, in turn, guide appropriate antibiotic prescribing. They noted that communication difficulties with prescribing physicians and lack of information sharing currently made it difficult to implement stewardship interventions, and they stated that they were interested in any intervention that could help overcome these barriers. CONCLUSION Community pharmacies represent an important point of contact for patients and are a potentially valuable setting for outpatient stewardship interventions. Pharmacists were overwhelmingly supportive of using CDS tools to evaluate patients and promote antimicrobial stewardship. These results suggest that it would be feasible to pilot such an intervention in the community pharmacy setting.
Collapse
|
30
|
Butler AM, Durkin MJ, Keller MR, Ma Y, Dharnidharka VR, Powderly WG, Olsen MA. Risk of antibiotic treatment failure in premenopausal women with uncomplicated urinary tract infection. Pharmacoepidemiol Drug Saf 2021; 30:1360-1370. [PMID: 33783918 DOI: 10.1002/pds.5237] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Revised: 03/10/2021] [Accepted: 03/19/2021] [Indexed: 11/11/2022]
Abstract
PURPOSE Acute uncomplicated urinary tract infections (UTIs) are among the most common indications for antibiotic prescriptions in otherwise healthy women. We compared the risk of treatment failure of antibiotic regimens for outpatient treatment of UTI in real-world practice. METHODS We identified non-pregnant, premenopausal women diagnosed with uncomplicated, lower tract UTI and prescribed an oral antibiotic with activity against common uropathogens. We used propensity score-weighted Kaplan-Meier functions to estimate 30-day risks and risk differences (RD) for pyelonephritis and UTI-related antibiotic prescription switch. RESULTS Of 1 140 602 patients, the distribution of index prescriptions was 44% fluoroquinolones (non-first-line), 28% trimethoprim-sulfamethoxazole (TMP/SMX) (first-line), 24% nitrofurantoin (first-line), 3% narrow-spectrum β-lactams (non-first-line), 1% broad-spectrum β-lactams (non-first-line), and 1% amoxicillin/ampicillin (non-recommended). Compared to the risk of pyelonephritis for nitrofurantoin (0.3%), risks were higher for TMP/SMX (RD, 0.2%; 95% CI, 0.2%-0.2%) and broad-spectrum β-lactams (RD, 0.2%; 95% CI, 0.1%-0.4%). Compared to the risk of prescription switch for nitrofurantoin (12.7%), the risk was higher for TMP/SMX (RD 1.6%; 95% CI 1.3%-1.7%) but similar for broad-spectrum β-lactams (RD -0.7%; 95% CI -1.4%-0.1%) and narrow-spectrum β-lactams (RD -0.3%; 95% CI -0.8%-0.2%). Subgroup analyses suggest TMP/SMX treatment failure may be due in part to increasing uropathogen resistance over time. CONCLUSIONS The risk of treatment failure differed by antibiotic agent, with higher risk associated with TMP/SMX versus nitrofurantoin, and lower or similar risk associated with broad- versus narrow-spectrum β-lactams. Given serious safety warnings for fluoroquinolones, these results suggest that nitrofurantoin may be preferable as the first-line agent for outpatient treatment of uncomplicated UTI.
Collapse
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
| | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew R Keller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Yinjiao Ma
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Vikas R Dharnidharka
- Department of Pediatrics, Division of Pediatric Nephrology, Washington University School of Medicine, St. Louis, Missouri, USA
| | - William G Powderly
- 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
| |
Collapse
|
31
|
Marks LR, Munigala S, Warren DK, Liss DB, Liang SY, Schwarz ES, Durkin MJ. A Comparison of Medication for Opioid Use Disorder Treatment Strategies for Persons Who Inject Drugs With Invasive Bacterial and Fungal Infections. J Infect Dis 2021; 222:S513-S520. [PMID: 32877547 DOI: 10.1093/infdis/jiz516] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 11/12/2022] Open
Abstract
BACKGROUND Patients with opioid use disorder (OUD) are frequently admitted for invasive infections. Medications for OUD (MOUD) may improve outcomes in hospitalized patients. METHODS In this retrospective cohort of 220 admissions to a tertiary care center for invasive infections due to OUD, we compared 4 MOUD treatment strategies: methadone, buprenorphine, methadone taper for detoxification, and no medication to determine whether there were differences in parenteral antibiotic completion and readmission rates. RESULTS The MOUDs were associated with increased completion of parenteral antimicrobial therapy (64.08% vs 46.15%; odds ratio [OR] = 2.08; 95% CI, 1.23-3.61). On multivariate analysis, use of MOUD maintenance with either buprenorphine (OR = 0.38; 95% CI, .17-.85) or methadone maintenance (OR = 0.43; 95% CI, .20-.94) and continuation of MOUD on discharge (OR = 0.35; 95% CI, .18-.67) was associated with lower 90-day readmissions. In contrast, use of methadone for detoxification followed by tapering of the medication without continuation on discharge was not associated with decreased readmissions (OR = 1.87; 95% CI, .62-5.10). CONCLUSIONS Long-term MOUDs, regardless of selection, are an integral component of care in patients hospitalized with OUD-related infections. Patients with OUD should have arrangements made for MOUDs to be continued after discharge, and MOUDs should not be discontinued before discharge.
Collapse
Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Satish Munigala
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - David K Warren
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - David B Liss
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Section of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Evan S Schwarz
- Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Section of Medical Toxicology, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
32
|
Upadhyaya A, Marks LR, Schwarz ES, Liang SY, Durkin MJ, Liss DB. Care cascade for patients with opioid use disorder and serious injection related infections. Toxicol Commun 2021; 5:6-10. [PMID: 33733021 DOI: 10.1080/24734306.2020.1869899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 10/22/2022] Open
Abstract
Objectives To define the care cascade for patients with serious injection drug use related infections (SIRI) in a tertiary hospital system and compare outcomes of those who did and did not participate in an opioid use disorder (OUD) treatment referral program. Methods The medical records of patients admitted with both OUD and SIRI including endocarditis, osteomyelitis, septic arthritis, epidural abscess, thrombophlebitis, myositis, bacteremia, and fungemia from 2016-2019 were retrospectively reviewed. Patient demographics, clinical covariates, 90-day readmission rates, and outcomes data were collected. We compared data from those who were successfully referred to outpatient care through Engaging Patients in Care Coordination (EPICC), a peer recovery specialist-run OUD treatment referral program, to those who did not receive outpatient referral. Results During the study period 334 persons who inject opioids were admitted with SIRI. Fourteen admitted patients died and were excluded from the analysis. The all-cause readmission rate was lower among patients referred to the EPICC program (18/76 [23.7%]) compared to those not referred to EPICC (100/244 [41.0%]) (OR 0.44; 95% CI 0.25 - 0.80). Conclusion An OUD care cascade evaluation for patients with SIRI demonstrated that referral to peer recovery services with outpatient OUD treatment was associated with reduced 90-day readmission rate.
Collapse
Affiliation(s)
- Anand Upadhyaya
- Department of Internal Medicine, Washington University in St. Louis School of Medicine
| | - Laura R Marks
- Department of Internal Medicine, Washington University in St. Louis School of Medicine.,Division of Infectious Diseases, Washington University in St. Louis School of Medicine
| | - Evan S Schwarz
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine.,Division of Medical Toxicology, Washington University in St. Louis School of Medicine
| | - Stephen Y Liang
- Department of Internal Medicine, Washington University in St. Louis School of Medicine.,Division of Infectious Diseases, Washington University in St. Louis School of Medicine.,Department of Emergency Medicine, Washington University in St. Louis School of Medicine
| | - Michael J Durkin
- Department of Internal Medicine, Washington University in St. Louis School of Medicine.,Division of Infectious Diseases, Washington University in St. Louis School of Medicine
| | - David B Liss
- Department of Emergency Medicine, Washington University in St. Louis School of Medicine.,Division of Medical Toxicology, Washington University in St. Louis School of Medicine
| |
Collapse
|
33
|
Marks LR, Liang SY, Muthulingam D, Schwarz ES, Liss DB, Munigala S, Warren DK, Durkin MJ. Evaluation of Partial Oral Antibiotic Treatment for Persons Who Inject Drugs and Are Hospitalized With Invasive Infections. Clin Infect Dis 2020; 71:e650-e656. [PMID: 32239136 PMCID: PMC7745005 DOI: 10.1093/cid/ciaa365] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Accepted: 03/31/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Persons who inject drugs (PWID) are at risk of invasive infections; however, hospitalizations to treat these infections are frequently complicated by against medical advice (AMA) discharges. This study compared outcomes among PWID who (1) completed a full course of inpatient intravenous (IV) antibiotics, (2) received a partial course of IV antibiotics but were not prescribed any antibiotics on AMA discharge, and (3) received a partial course of IV antibiotics and were prescribed oral antibiotics on AMA discharge. METHODS A retrospective, cohort study of PWID aged ≥18 years admitted to a tertiary referral center between 01/2016 and 07/2019, who received an infectious diseases consultation for an invasive bacterial or fungal infection. RESULTS 293 PWID were included in the study. 90-day all-cause readmission rates were highest among PWID who did not receive oral antibiotic therapy on AMA discharge (n = 46, 68.7%), compared with inpatient IV (n = 43, 31.5%) and partial oral (n = 27, 32.5%) antibiotics. In a multivariate analysis, 90-day readmission risk was higher among PWID who did not receive oral antibiotic therapy on AMA discharge (adjusted hazard ratio [aHR], 2.32; 95% confidence interval [CI], 1.41-3.82) and not different among PWID prescribed oral antibiotic therapy on AMA discharge (aHR, .99; 95% CI, .62-1.62). Surgical source control (aHR, .57; 95% CI, .37-.87) and addiction medicine consultation (aHR, .57; 95% CI, .38-.86) were both associated with reduced readmissions. CONCLUSIONS Our single-center study suggests access to oral antibiotic therapy for PWID who cannot complete prolonged inpatient IV antibiotic courses is beneficial.
Collapse
Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Dharushana Muthulingam
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Evan S Schwarz
- Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Section of Medical Toxicology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - David B Liss
- Division of Emergency Medicine, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
- Section of Medical Toxicology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Satish Munigala
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - David K Warren
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| |
Collapse
|
34
|
Thornhill MH, Gibson TB, Durkin MJ, Dayer MJ, Lockhart PB, O'Gara PT, Baddour LM. Prescribing of antibiotic prophylaxis to prevent infective endocarditis. J Am Dent Assoc 2020; 151:835-845.e31. [PMID: 33121605 DOI: 10.1016/j.adaj.2020.07.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 07/22/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND In 2007, the American Heart Association recommended that antibiotic prophylaxis (AP) be restricted to those at high risk of developing complications due to infective endocarditis (IE) undergoing invasive dental procedures. The authors aimed to estimate the appropriateness of AP prescribing according to type of dental procedure performed in patients at high risk, moderate risk, or low or unknown risk of developing IE complications. METHODS Eighty patients at high risk, 40 patients at moderate risk, and 40 patients at low or unknown risk of developing IE complications were randomly selected from patients with linked dental care, health care, and prescription benefits data in the IBM MarketScan Databases, one of the largest US health care convenience data samples. Two clinicians independently analyzed prescription and dental procedure data to determine whether AP prescribing was likely, possible, or unlikely for each dental visit. RESULTS In patients at high risk of developing IE complications, 64% were unlikely to have received AP for invasive dental procedures, and in 32 of 80 high-risk patients (40%) there was no evidence of AP for any dental visit. When AP was prescribed, several different strategies were used to provide coverage for multiple dental visits, including multiday courses, multidose prescriptions, and refills, which sometimes led to an oversupply of antibiotics. CONCLUSIONS AP prescribing practices were inconsistent, did not always meet the highest antibiotic stewardship standards, and made retrospective evaluation difficult. For those at high risk of developing IE complications, there appears to be a concerning level of underprescribing of AP for invasive dental procedures. PRACTICAL IMPLICATIONS Some dentists might be failing to fully comply with American Heart Association recommendations to provide AP cover for all invasive dental procedures in those at high risk of developing IE complications.
Collapse
|
35
|
Marks LR, Nolan NS, Jiang L, Muthulingam D, Liang SY, Durkin MJ. Use of ICD-10 Codes for Identification of Injection Drug Use-Associated Infective Endocarditis Is Nonspecific and Obscures Critical Findings on Impact of Medications for Opioid Use Disorder. Open Forum Infect Dis 2020; 7:ofaa414. [PMID: 33094117 PMCID: PMC7566393 DOI: 10.1093/ofid/ofaa414] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [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: 06/11/2020] [Accepted: 09/03/2020] [Indexed: 12/02/2022] Open
Abstract
Background No International Classification of Diseases, 10th revision (ICD-10), diagnosis code exists for injection drug use–associated infective endocarditis (IDU-IE). Instead, public health researchers regularly use combinations of nonspecific ICD-10 codes to identify IDU-IE; however, the accuracy of these codes has not been evaluated. Methods We compared commonly used ICD-10 diagnosis codes for IDU-IE with a prospectively collected patient cohort diagnosed with IDU-IE at Barnes-Jewish Hospital to determine the accuracy of ICD-10 diagnosis codes used in IDU-IE research. Results ICD-10 diagnosis codes historically used to identify IDU-IE were inaccurate, missing 36.0% and misclassifying 56.4% of patients prospectively identified in this cohort. Use of these nonspecific ICD-10 diagnosis codes resulted in substantial biases against the benefit of medications for opioid use disorder (MOUD) with relation to both AMA discharge and all-cause mortality. Specifically, when data from all patients with ICD-10 code combinations suggestive of IDU-IE were used, MOUD was associated with an increased risk of AMA discharge (relative risk [RR], 1.12; 95% CI, 0.48–2.64). In contrast, when only patients confirmed by chart review as having IDU-IE were analyzed, MOUD was protective (RR, 0.49; 95% CI, 0.19–1.22). Use of MOUD was associated with a protective effect in time to all-cause mortality in Kaplan-Meier analysis only when confirmed IDU-IE cases were analyzed (P = .007). Conclusions Studies using nonspecific ICD-10 diagnosis codes for IDU-IE should be interpreted with caution. In the setting of an ongoing overdose crisis and a syndemic of infectious complications, a specific ICD-10 diagnosis code for IDU-IE is urgently needed.
Collapse
Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Nathanial S Nolan
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Linda Jiang
- Division of Medical Education, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Dharushana Muthulingam
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen Y Liang
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA.,Division of Emergency Medicine, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| |
Collapse
|
36
|
Foong KS, Hsueh K, Bailey TC, Luong L, Iqbal A, Hoehner C, Connor L, Casabar E, Lane M, Burnett Y, Ritchie D, Krekel T, Newland H, Weilmuenster L, Heuring B, Durkin MJ, Hamad Y. A Cluster of Cefepime-induced Neutropenia During Outpatient Parenteral Antimicrobial Therapy. Clin Infect Dis 2020; 69:534-537. [PMID: 30590400 DOI: 10.1093/cid/ciy1112] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 11/09/2018] [Accepted: 12/21/2018] [Indexed: 01/20/2023] Open
Abstract
A cluster of cefepime-induced neutropenia (CIN) was identified from June 2017 to May 2018 in a regional outpatient parenteral antimicrobial therapy population. Our data suggest prolonged courses of cefepime (≥2 weeks), administered by rapid intravenous push, were associated with a higher risk of CIN.
Collapse
Affiliation(s)
- Kap Sum Foong
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine
| | - Kevin Hsueh
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine
| | - Thomas C Bailey
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine
| | - Lan Luong
- Center for Clinical Excellence, BJC HealthCare
| | | | | | - Lee Connor
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine
| | - Ed Casabar
- Department of Pharmacy, Barnes-Jewish Hospital
| | - Michael Lane
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine
| | - Yvonne Burnett
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine.,Department of Pharmacy Practice, St. Louis College of Pharmacy
| | - David Ritchie
- Department of Pharmacy, Barnes-Jewish Hospital.,Department of Pharmacy Practice, St. Louis College of Pharmacy
| | | | | | | | | | - Michael J Durkin
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine
| | - Yasir Hamad
- Division of Infectious Diseases, Department of Medicine, Washington University School of Medicine
| |
Collapse
|
37
|
Marks LR, Munigala S, Warren DK, Liang SY, Schwarz ES, Durkin MJ. Addiction Medicine Consultations Reduce Readmission Rates for Patients With Serious Infections From Opioid Use Disorder. Clin Infect Dis 2020; 68:1935-1937. [PMID: 30357363 DOI: 10.1093/cid/ciy924] [Citation(s) in RCA: 119] [Impact Index Per Article: 29.8] [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: 09/11/2018] [Accepted: 10/22/2018] [Indexed: 11/13/2022] Open
Abstract
The opioid epidemic has increased hospital admissions for serious infections related to opioid abuse. Our findings demonstrate that addiction medicine consultation is associated with increased treatment for opioid use disorder (OUD), greater likelihood of completing antimicrobial therapy, and reduced readmission rates among patients with OUD and serious infections requiring hospitalization.
Collapse
Affiliation(s)
- Laura R Marks
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, Missouri
| | - Satish Munigala
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, Missouri
| | - David K Warren
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, Missouri
| | - Stephen Y Liang
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, Missouri.,Division of Emergency Medicine, School of Medicine, Washington University in St Louis, Missouri
| | - Evan S Schwarz
- Division of Emergency Medicine, School of Medicine, Washington University in St Louis, Missouri.,Section of Medical Toxicology, School of Medicine, Washington University in St Louis, Missouri
| | - Michael J Durkin
- Division of Infectious Diseases, School of Medicine, Washington University in St Louis, Missouri
| |
Collapse
|
38
|
Thornhill MH, Dayer MJ, Durkin MJ, Lockhart PB, Baddour LM. Response to the Letter to the Editor: "Risk of Adverse Reactions to Oral Antibiotics Prescribed by Dentists". J Dent Res 2020; 99:864. [PMID: 32282272 DOI: 10.1177/0022034520917140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- M H Thornhill
- Unit of Oral & Maxillofacial Medicine Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, UK.,Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - M J Dayer
- Department of Cardiology, Taunton and Somerset NHS Trust, Taunton, Somerset, UK
| | - M J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - P B Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, NC, USA
| | - L M Baddour
- Division of Infectious Diseases, Department of Medicine and the Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| |
Collapse
|
39
|
Thornhill MH, Suda KJ, Durkin MJ, Lockhart PB. Authors' response. J Am Dent Assoc 2020; 151:5-6. [PMID: 31902399 DOI: 10.1016/j.adaj.2019.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Martin H Thornhill
- Professor, Translational Research in Dentistry, Unit of Oral & Maxillofacial Medicine Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, UK; Adjunct Professor, Department of Oral Medicine, Carolinas Medical Center-Atrium Health, Charlotte, NC
| | - Katie J Suda
- Research Health Scientist, Center of Innovation for Complex Chronic Healthcare, Edward Hines, Jr. VA Hospital and, Associate Professor, College of Pharmacy, University of Illinois at Chicago, College of Pharmacy, Chicago, IL
| | - Michael J Durkin
- Assistant Professor, Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO
| | - Peter B Lockhart
- Research Professor, Department of Oral Medicine, Carolinas Medical Center-Atrium Health, Charlotte, NC
| |
Collapse
|
40
|
Abstract
Introduction Dentists prescribe a significant proportion of all antibiotics, while antimicrobial stewardship aims to minimise antibiotic-prescribing to reduce the risk of developing antibiotic-resistance and adverse drug reactions.Aims To evaluate NHS antibiotic-prescribing practices of dentists in England between 2010-2017.Methods NHS Digital 2010-2017 data for England were analysed to quantify dental and general primary-care oral antibiotic prescribing.Results Dental prescribing accounted for 10.8% of all oral antibiotic prescribing, 18.4% of amoxicillin and 57.0% of metronidazole prescribing in primary care. Amoxicillin accounted for 64.8% of all oral antibiotic prescribing by dentists, followed by metronidazole (28.0%), erythromycin (4.4%), phenoxymethylpenicillin (0.9%), clindamycin (0.6%), co-amoxiclav (0.5%), cephalosporins (0.4%) and tetracyclines (0.3%). Prescriptions by dentists declined during the study period for all antibiotics except for co-amoxiclav. This increase is of concern given the need to restrict co-amoxiclav use to infections where there is no alternative. Dental prescribing of clindamycin, which accounted for 43.9% of primary care prescribing in 2010, accounted for only 14.6% in 2017. Overall oral antibiotic prescribing by dentists fell 24.4% as compared to 14.8% in all of primary care.Conclusions These data suggest dentists have reduced antibiotic prescribing, possibly more than in other areas of primary-care. Nonetheless, opportunities remain for further reduction.
Collapse
Affiliation(s)
- Martin H Thornhill
- Unit of Oral & Maxillofacial Medicine Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, UK; Department of Oral Medicine, Carolinas Medical Centre, Charlotte, NC, USA.
| | - Mark J Dayer
- Department of Cardiology, Taunton and Somerset NHS Trust, Taunton, Somerset, UK
| | - Michael J Durkin
- Division of Infectious Diseases, Washington University in St. Louis School of Medicine, MO, USA
| | - Peter B Lockhart
- Department of Oral Medicine, Carolinas Medical Centre, Charlotte, NC, USA
| | - Larry M Baddour
- Division of Infectious Diseases, Department of Medicine and the Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, MN, USA
| |
Collapse
|
41
|
Tampi MP, Pilcher L, Urquhart O, Kennedy E, O'Brien KK, Lockhart PB, Abt E, Aminoshariae A, Durkin MJ, Fouad AF, Gopal P, Hatten BW, Lang MS, Patton LL, Paumier T, Suda KJ, Cho H, Carrasco-Labra A. Antibiotics for the urgent management of symptomatic irreversible pulpitis, symptomatic apical periodontitis, and localized acute apical abscess: Systematic review and meta-analysis-a report of the American Dental Association. J Am Dent Assoc 2019; 150:e179-e216. [PMID: 31761029 DOI: 10.1016/j.adaj.2019.09.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Patients with pulpal and periapical conditions often seek treatment for pain, intraoral swelling, or both. Even when definitive, conservative dental treatment (DCDT) is an option, antibiotics are often prescribed. The purpose of this review was to summarize available evidence regarding the effect of antibiotics, either alone or as adjuncts to DCDT, to treat immunocompetent adults with pulpal and periapical conditions, as well as additional population-level harms associated with antibiotic use. TYPE OF STUDIES REVIEWED The authors updated 2 preexisting systematic reviews to identify newly published randomized controlled trials. They also searched for systematic reviews to inform additional harm outcomes. They conducted searches in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature. Pairs of reviewers independently conducted study selection, data extraction, and assessment of risk of bias and certainty in the evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. RESULTS The authors found no new trials via the update of the preexisting reviews. Ultimately, 3 trials and 8 additional reports proved eligible for this review. Trial estimates for all outcomes suggested both a benefit and harm over 7 days (very low to low certainty evidence). The magnitude of additional harms related to antibiotic use for any condition were potentially large (very low to moderate certainty evidence). CONCLUSIONS AND PRACTICAL IMPLICATIONS Evidence for antibiotics, either alone or as adjuncts to DCDT, showed both a benefit and a harm for outcomes of pain and intraoral swelling and a large potential magnitude of effect in regard to additional harm outcomes. The impact of dental antibiotic prescribing requires further research.
Collapse
|
42
|
Lockhart PB, Tampi MP, Abt E, Aminoshariae A, Durkin MJ, Fouad AF, Gopal P, Hatten BW, Kennedy E, Lang MS, Patton LL, Paumier T, Suda KJ, Pilcher L, Urquhart O, O'Brien KK, Carrasco-Labra A. Evidence-based clinical practice guideline on antibiotic use for the urgent management of pulpal- and periapical-related dental pain and intraoral swelling: A report from the American Dental Association. J Am Dent Assoc 2019; 150:906-921.e12. [PMID: 31668170 PMCID: PMC8270006 DOI: 10.1016/j.adaj.2019.08.020] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 08/21/2019] [Accepted: 08/22/2019] [Indexed: 01/21/2023]
Abstract
BACKGROUND An expert panel convened by the American Dental Association Council on Scientific Affairs and the Center for Evidence-Based Dentistry conducted a systematic review and formulated clinical recommendations for the urgent management of symptomatic irreversible pulpitis with or without symptomatic apical periodontitis, pulp necrosis and symptomatic apical periodontitis, or pulp necrosis and localized acute apical abscess using antibiotics, either alone or as adjuncts to definitive, conservative dental treatment (DCDT) in immunocompetent adults. TYPES OF STUDIES REVIEWED The authors conducted a search of the literature in MEDLINE, Embase, the Cochrane Library, and the Cumulative Index to Nursing and Allied Health Literature to retrieve evidence on benefits and harms associated with antibiotic use. The authors used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty in the evidence and the Evidence-to-Decision framework. RESULTS The panel formulated 5 clinical recommendations and 2 good practice statements, each specific to the target conditions, for settings in which DCDT is and is not immediately available. With likely negligible benefits and potentially large harms, the panel recommended against using antibiotics in most clinical scenarios, irrespective of DCDT availability. They recommended antibiotics in patients with systemic involvement (for example, malaise or fever) due to the dental conditions or when the risk of experiencing progression to systemic involvement is high. CONCLUSION AND PRACTICAL IMPLICATIONS Evidence suggests that antibiotics for the target conditions may provide negligible benefits and probably contribute to large harms. The expert panel suggests that antibiotics for target conditions be used only when systemic involvement is present and that immediate DCDT should be prioritized in all cases.
Collapse
|
43
|
Thornhill MH, Suda KJ, Durkin MJ, Lockhart PB. Is it time US dentistry ended its opioid dependence? J Am Dent Assoc 2019; 150:883-889. [PMID: 31561762 PMCID: PMC7951996 DOI: 10.1016/j.adaj.2019.07.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 06/28/2019] [Accepted: 07/02/2019] [Indexed: 11/19/2022]
Abstract
BACKGROUND In 2017, 11.4 million US citizens misused prescription opioids, resulting in 46 overdose deaths daily and a $78.5 billion burden on the economy. Dentists are one of the most frequent prescribers of opioids, and there is concern that dental prescribing is contributing to the opioid crisis. METHODS A 2019 study showed 22.3% of US dental prescriptions were for opioids compared with 0.6% of dental prescriptions in England where nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen accounted for most analgesic prescriptions. This observation prompted a review of international analgesic prescribing habits and of the advantages and disadvantages of opioids and NSAIDs for treating dental pain. RESULTS US opioid prescribing far exceeded that in other countries where NSAIDs accounted for most dental analgesic prescribing. Furthermore, results from reviews published respectively in 2018 and 2016 help confirm that NSAIDs and NSAID-acetaminophen combinations are as effective as or more effective than opioids for controlling dental pain and cause significantly fewer adverse effects. CONCLUSIONS In light of the potential for misuse and evidence that NSAIDs are as effective as opioids and have fewer adverse effects, there is clear patient benefit in avoiding opioids for the prevention or management of dental pain. PRACTICAL IMPLICATIONS A growing preponderance of evidence shows that opioids are not needed for routine oral health care. This article provides an overview of the evidence and outlines possible pain management models to minimize opioid use in dentistry. The purpose is to stimulate debate about this important topic and encourage the development of definitive guidance by professional bodies, health care providers, and state and federal agencies.
Collapse
|
44
|
Abstract
IMPORTANCE The United States consumes most of the opioids worldwide despite representing a small portion of the world's population. Dentists are one of the most frequent US prescribers of opioids despite data suggesting that nonopioid analgesics are similarly effective for oral pain. While oral health and dentist use are generally similar between the United States and England, it is unclear how opioid prescribing by dentists varies between the 2 countries. OBJECTIVE To compare opioid prescribing by dentists in the United States and England. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of prescriptions for opioids dispensed from outpatient pharmacies and health care settings between January 1 and December 31, 2016, by dentists in the United States and England. Data were analyzed from October 2018 to January 2019. EXPOSURES Opioids prescribed by dentists. MAIN OUTCOMES AND MEASURES Proportion and prescribing rates of opioid prescriptions. RESULTS In 2016, the proportion of prescriptions written by US dentists that were for opioids was 37 times greater than the proportion written by English dentists. In all, 22.3% of US dental prescriptions were opioids (11.4 million prescriptions) compared with 0.6% of English dental prescriptions (28 082 prescriptions) (difference, 21.7%; 95% CI, 13.8%-32.1%; P < .001). Dentists in the United States also had a higher number of opioid prescriptions per 1000 population (35.4 per 1000 US population [95% CI, 25.2-48.7 per 1000 population] vs 0.5 per 1000 England population [95% CI, 0.03-3.7 per 1000 population]) and number of opioid prescriptions per dentist (58.2 prescriptions per dentist [95% CI, 44.9-75.0 prescriptions per dentist] vs 1.2 prescriptions per dentist [95% CI, 0.2-5.6 prescriptions per dentist]). While the codeine derivative dihydrocodeine was the sole opioid prescribed by English dentists, US dentists prescribed a range of opioids containing hydrocodone (62.3%), codeine (23.2%), oxycodone (9.1%), and tramadol (4.8%). Dentists in the United States also prescribed long-acting opioids (0.06% of opioids prescribed by US dentists [6425 prescriptions]). Long-acting opioids were not prescribed by English dentists. CONCLUSIONS AND RELEVANCE This study found that in 2016, dentists in the United States prescribed opioids with significantly greater frequency than their English counterparts. Opioids with a high potential for abuse, such as oxycodone, were frequently prescribed by US dentists but not prescribed in England. These results illustrate how 1 source of opioids differs substantially in the United States vs England. To reduce dental opioid prescribing in the United States, dentists could adopt measures similar to those used in England, including national guidelines for treating dental pain that emphasize prescribing opioids conservatively.
Collapse
Affiliation(s)
- Katie J. Suda
- Center of Innovation for Complex Chronic Healthcare, Edward Hines Jr Veterans Administration Hospital, Chicago, Illinois
- College of Pharmacy, University of Illinois at Chicago
| | - Michael J. Durkin
- School of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Walid F. Gellad
- Center for Health Equity Research and Promotion, Pittsburgh Veterans Administration Healthcare System, Pittsburgh, Pennsylvania
- School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Hajwa Kim
- Center for Clinical and Translational Science, University of Illinois at Chicago
| | - Peter B. Lockhart
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina
| | | | - Martin H. Thornhill
- Department of Oral Medicine, Carolinas Medical Center, Charlotte, North Carolina
- School of Clinical Dentistry, University of Sheffield, Sheffield, United Kingdom
| |
Collapse
|
45
|
Liu S, Bongu J, Keller M, Butler AM, Olsen MA, Durkin MJ. 1512. Variation in Outpatient Urine Testing Practices for Uncomplicated Urinary Tract Infections. Open Forum Infect Dis 2018. [PMCID: PMC6253352 DOI: 10.1093/ofid/ofy210.1341] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Urinary tract infections (UTIs) are common in outpatient settings. Evidence-based recommendations suggest empiric treatment of healthy female patients presenting with two or more classic symptoms of UTIs, rather than urine testing. It is unknown how often urine testing is ordered in the community, and if there are opportunities to reduce the number of unnecessary urine tests. This study aims to describe urine testing practices for uncomplicated UTIs in outpatient settings. Methods Using the 2009–2013 Truven Health Analytics MarketScan database, we extracted outpatient claims data for premenopausal, nonpregnant women aged 18–44 years who met criteria for an uncomplicated UTI or cystitis with antibiotic prescribed ±5 days of diagnosis. Women with recent infections, hospitalizations, urologic abnormalities, diabetes, chronic kidney disease, immune compromise, or other complicating factors were excluded. Urine laboratory tests coded within ±5 days of index UTI were identified. To explore variation in urine testing practices, we compared frequencies of urine testing types according to patient age, region, provider type, testing location, residence in a metropolitan statistical area (MSA), and office visit using Chi-square tests. Results Of 669,892 eligible patients with an uncomplicated UTI, 584,863 (87%) received at least one urine test. Of the patients who received at least one test, 285,639 (49%) patients received both a urinalysis (UA) and culture, 247,740 (42%) received a UA only, and 51,484 (9%) received culture only. Significant variation in testing was observed by patient age, region, provider type, testing location, and office visit (Table 1). Patients in the Northeast and in urban locations more frequently received both a UA and culture. Patients who received both UA and culture were more likely to have been seen by an OB/GYN, whereas patients treated empirically without testing were more likely to have been seen by emergency physicians. Conclusion In contrast to evidence-based recommendations, the vast majority of patients with uncomplicated UTI received at least one urine test. We observed variation in urine testing practices, which suggests that diagnostic testing stewardship opportunities exist for outpatients with UTIs. ![]()
Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Sonya Liu
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| | - Jahnavi Bongu
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| | - Matthew Keller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| | - Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
- Division of Public Health Sciences, Washington University School of Medicine, St. Louis, Missouri
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
- Washington University School of Medicine, Saint Louis, Missouri
| | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, Saint Louis, Missouri
| |
Collapse
|
46
|
Bergin SP, Coles A, Calvert SB, Farley J, Santiago J, Zervos MJ, Bardossy AC, Kollef M, Durkin MJ, Sims M, Greenshields C, Kabchi BA, Donnelly HK, III JP, Tenaerts P, Gu P, Fowler VG, Holland TL. 872. PROPHETIC: Predicting Pneumonia in Hospitalized Patients in the ICU—A Model and Scoring System. Open Forum Infect Dis 2018. [PMCID: PMC6252450 DOI: 10.1093/ofid/ofy209.056] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Prospectively identifying patients at highest risk for hospital-acquired and ventilator-associated bacterial pneumonia (HABP/VABP) by implementing a risk assessment scoring tool may help focus prevention efforts, optimize the screening process to improve clinical trial feasibility, and enhance development of new antibacterial agents. Methods Within the intensive care units (ICU) of 28 US hospitals, between February 6, 2016 and October 7, 2016, patients hospitalized >48 hours and receiving high levels of respiratory support were prospectively followed for meeting the definition of HABP/VABP recommended in US FDA draft guidance. Patient demographics, medical comorbidities, and treatment exposures were recorded. The association between candidate risk factors and odds of developing HABP/VABP was evaluated with a multivariable logistic regression model. Risk factors were selected using backward selection with α = 0.1 for model inclusion. A web-based scoring system was developed to estimate the risk of HABP/VABP from the risk factors identified. Results A total of 5,101 patients were enrolled, of whom 1,005 (20%) developed HABP/VABp. 4,613 patients were included in the model, excluding 488 (10%) with HABP/VABP at or before enrollment. There are 15 variables included in the model. APACHE II admission score >20 (P < 0.001, OR 2.14, 95% CI 2.00–2.29), admission diagnosis of trauma (P < 0.001, OR 3.31, 95% CI 1.90–5.74), frequent oral or lower respiratory tract suctioning (P < 0.001, OR 2.33, 95% CI 1.81–2.99), and receipt of enteral nutrition (P < 0.001, OR 2.31, 95% CI 1.69–3.16) were the key drivers of increased pneumonia risk. The model demonstrated excellent discrimination (bias-corrected C-statistic 0.861, 95% CI 0.843–0.880). The web-based scoring system can be accessed via this link: https://ctti-habpvabp.shinyapps.io/web_based_tool/. Conclusion Using a web-based scoring system, ICU patients at highest risk for developing HABP/VABP can be accurately identified. Prospective implementation of this tool may assist in focusing additional prevention efforts on the highest risk patients and enhance new drug development for HABP/VABP. Disclosures S. P. Bergin, CTTI: Investigator and Scientific Advisor, Research support and Travel to study related meetings. A. Coles, CTTI: Investigator and Scientific Advisor, Salary. S. B. Calvert, CTTI: Employee, Salary. M. J. Zervos, CTTI: Investigator, Research support. A. C. Bardossy, CTTI: Investigator, Research support. M. Kollef, CTTI: Investigator, Research support. M. J. Durkin, CTTI: Investigator, Research support. M. Sims, CTTI: Investigator, Research support. C. Greenshields, CTTI: Investigator, Research support. B. A. Kabchi, CTTI: Investigator, Research support. H. K. Donnelly, CTTI: Collaborator and Scientific Advisor, Research support and Salary. P. Tenaerts, CTTI: Employee, Salary. P. Gu, CTTI: Collaborator, Research support and Salary. V. G. Fowler Jr., CTTI: Investigator and Scientific Advisor, Research support and Salary. Merck: Consultant, Grant Investigator and Scientific Advisor, Consulting fee, Grant recipient and Research support. Cerexa/Actavis/Allegan: Grant Investigator, Grant recipient. Pfizer: Consultant and Grant Investigator, Consulting fee and Grant recipient. Advanced Liquid Logics: Grant Investigator, Grant recipient. NIH: Investigator, Grant recipient, Research support and Salary. MedImmune: Consultant and Grant Investigator, Consulting fee and Grant recipient. Basilea: Consultant and Grant Investigator, Consulting fee and Grant recipient. Karius: Grant Investigator, Grant recipient. Contrafect: Consultant and Grant Investigator, Consulting fee and Grant recipient. Regeneron: Grant Investigator, Grant recipient. Genentech: Consultant and Grant Investigator, Consulting fee and Grant recipient. Achaogen: Consultant, Consulting fee. Astellas: Consultant, Consulting fee. Arsanis: Consultant, Consulting fee. Affinergy: Consultant, Consulting fee. Bayer: Consultant, Consulting fee. Cerexa: Consultant, Consulting fee. Cubist: Consultant, Consulting fee. Debiopharm: Consultant, Consulting fee. Durata: Consultant, Consulting fee. Grifols: Consultant, Consulting fee. Medicines Co.: Consultant, Consulting fee. Novartis: Consultant, Consulting fee. Novadigm: Consultant, Consulting fee. Theravance: Consultant, Consulting fee and Speaker honorarium. xBiotech: Consultant, Consulting fee. Green Cross: Consultant, Speaker honorarium. T. L. Holland, CTTI: Investigator and Scientific Advisor, Research support and Salary.
Collapse
Affiliation(s)
| | - Adrian Coles
- Duke Clinical Research Institute, Durham, North Carolina
| | - Sara B Calvert
- Clinical Trials Transformation Initiative (CTTI), Durham, North Carolina
| | | | | | | | | | - Marin Kollef
- Washington University School of Medicine, St. Louis, Missouri
| | | | | | | | | | | | - John Powers III
- George Washington University School of Medicine, Washington, DC
| | - Pamela Tenaerts
- Clinical Trials Transformation Initiative (CTTI), Durham, North Carolina
| | - Peidi Gu
- Duke Clinical Research Institute, Durham, North Carolina
| | - Vance G Fowler
- Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| | - Thomas L Holland
- Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Durham, North Carolina
| |
Collapse
|
47
|
Butler AM, Keller MR, Durkin MJ, Dharnidharka VR, Olsen MA. 1501. Comparative Effectiveness of Antibiotic Therapy for the Outpatient Treatment of Urinary Tract Infections Among Otherwise Healthy, Premenopausal Women. Open Forum Infect Dis 2018. [PMCID: PMC6253666 DOI: 10.1093/ofid/ofy210.1330] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background The comparative effectiveness of antibiotics for empiric therapy for urinary tract infection (UTI) is not well established. We sought to estimate the risk of treatment failure by guideline-recommended agent for treatment of UTI in otherwise healthy, premenopausal women. Methods Using US commercial insurance claims data (2006–2015), we conducted a retrospective cohort study of nonpregnant women 18–44 years who received an outpatient diagnosis of UTI with a prescription for an antibiotic with activity against common uropathogens. For each antibiotic agent, we estimated the daily cumulative risk and 95% confidence intervals (CIs) of treatment failure defined by a subsequent UTI-related antibiotic prescription since the index prescription. Propensity-score weighting accounted for patient-, geographic-, and provider-level characteristics. Results Among 1,100,661 eligible women, the majority received second-line fluoroquinolones (43%), first-line trimethoprim-sulfamethoxazole (28%), or first-line nitrofurantoin (24%). Seven-day and 30-day treatment failure occurred in 8.4% (n = 92,382) and 20.5% (n = 225,746) of women, respectively. Among initiators of first-line agents, the 7-day weighted cumulative incidence estimates of treatment failure were lower for nitrofurantoin (6.0%, 95% CI, 5.9%–6.1%) vs. trimethoprim-sulfamethoxazole (8.8%, 95% CI, 8.7%–9.0%). Among initiators of second-line agents, treatment failure did not differ between fluoroquinolones (5.0%, 95% CI, 4.9%–5.1%), narrow-spectrum β-lactams (5.1%, 95% CI, 4.9%–5.4%), or broad-spectrum β-lactams (5.3%, 95% CI, 4.9%–5.7%). Among initiators of nonguideline recommended β-lactams, treatment failure was 9.6% (95% CI, 9.0%–10.3%). Results were similar for 30-day treatment failure, with the exception of lower risk for fluoroquinolones compared with other second-line agents. Conclusion The risk of treatment failure differs widely by antibiotic agent, with substantial differences between two first-line agents. Understanding the effectiveness of antibiotic therapy is critical to guide clinical decision making, reduce suboptimal antibiotic prescribing, and prevent antibiotic resistance and other adverse events. Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
- Anne M Butler
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew R Keller
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Michael J Durkin
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| | - Vikas R Dharnidharka
- Department of Pediatrics, Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri
| | - Margaret A Olsen
- Department of Medicine, Division of Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri
| |
Collapse
|
48
|
Britt NS, Ritchie DJ, Kollef MH, Burnham CAD, Durkin MJ, Hampton NB, Micek ST. Clinical epidemiology of carbapenem-resistant gram-negative sepsis among hospitalized patients: Shifting burden of disease? Am J Infect Control 2018; 46:1092-1096. [PMID: 29706365 DOI: 10.1016/j.ajic.2018.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 03/13/2018] [Accepted: 03/13/2018] [Indexed: 01/10/2023]
Abstract
BACKGROUND Infections caused by carbapenem-resistant gram-negative bacilli are an emerging public health threat. However, there is a paucity of data examining comparative incidence rates, risk factors, and outcomes in this population. METHODS This single-center retrospective cohort study was conducted at an urban tertiary-care academic medical center. We included patients admitted from 2012 to 2015 who met the following criteria: i) age ≥ 18 years; and ii) culture positive for carbapenem-resistant Enterobacteriaceae (CRE) or carbapenem-resistant non-Enterobacteriaceae (CRNE) from any site. Exclusion criteria were: i) < 2 systemic inflammatory response criteria; ii) cystic fibrosis; and iii) no targeted treatment. We evaluated hospital survival by Cox regression and year-by-year differences in the distribution of cases by the Cochran-Armitage test. RESULTS 448 patients were analyzed (CRE, n = 111 [24.8%]; CRNE, n = 337 [75.2%]). CRE sepsis cases increased significantly over the study period (P <.001), driven primarily by increasing incidence of Enterobacter spp. infection (P = .004). No difference was observed in hospital survival between patients with CRE versus CRNE sepsis (hazard ratio [HR], 1.29; 95% confidence interval [CI], 0.83-2.02; P = .285), even after adjusting for confounding factors (adjusted HR, 1.08; 95% CI, 0.62-1.87; P = .799). CONCLUSIONS Clinical outcomes did not differ between patients with CRE versus CRNE sepsis. Dramatic increases in CRE, particularly Enterobacter spp., appear to be causing a shift in the burden of clinically significant carbapenem-resistant gram-negative infection.
Collapse
|
49
|
Durkin MJ, Keller M, Butler AM, Kwon JH, Dubberke ER, Miller AC, Polgreen PM, Olsen MA. An Assessment of Inappropriate Antibiotic Use and Guideline Adherence for Uncomplicated Urinary Tract Infections. Open Forum Infect Dis 2018; 5:ofy198. [PMID: 30191156 PMCID: PMC6121225 DOI: 10.1093/ofid/ofy198] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 08/08/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In 2011, The Infectious Diseases Society of America released a clinical practice guideline (CPG) that recommended short-course antibiotic therapy and avoidance of fluoroquinolones for uncomplicated urinary tract infections (UTIs). Recommendations from this CPG were rapidly disseminated to clinicians via review articles, UpToDate, and the Centers for Disease Control and Prevention website; however, it is unclear if this CPG had an impact on national antibiotic prescribing practices. METHODS We performed a retrospective cohort study of outpatient and emergency department visits within a commercial insurance database between January 1, 2009, and December 31, 2013. We included nonpregnant women aged 18-44 years who had an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a UTI with a concurrent antibiotic prescription. We performed interrupted time series analyses to determine the impact of the CPG on the appropriateness of the antibiotic agent and duration. RESULTS We identified 654 432 women diagnosed with UTI. The patient population was young (mean age, 31 years) and had few comorbidities. Fluoroquinolones, nonfirstline agents, were the most commonly prescribed antibiotic class both before and after release of the guidelines (45% vs 42%). Wide variation was observed in the duration of treatment, with >75% of prescriptions written for nonrecommended treatment durations. The CPG had minimal impact on antibiotic prescribing behavior by providers. CONCLUSIONS Inappropriate antibiotic prescribing is common for the treatment of UTIs. The CPG was not associated with a clinically meaningful change in national antibiotic prescribing practices for UTIs. Further interventions are necessary to improve outpatient antibiotic prescribing for UTIs.
Collapse
Affiliation(s)
- Michael J Durkin
- Division of Infectious Diseases, Department of Internal Medicine
| | - Matthew Keller
- Division of Infectious Diseases, Department of Internal Medicine
| | - Anne M Butler
- Division of Infectious Diseases, Department of Internal Medicine
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| | - Jennie H Kwon
- Division of Infectious Diseases, Department of Internal Medicine
| | - Erik R Dubberke
- Division of Infectious Diseases, Department of Internal Medicine
| | | | - Phillip M Polgreen
- Department of Epidemiology, College of Public Health
- Department of Internal Medicine, University of Iowa, Iowa City, Iowa
| | - Margaret A Olsen
- Division of Infectious Diseases, Department of Internal Medicine
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri
| |
Collapse
|
50
|
Durkin MJ, Feng Q, Warren K, Lockhart PB, Thornhill MH, Munshi KD, Henderson RR, Hsueh K, Fraser VJ. Assessment of inappropriate antibiotic prescribing among a large cohort of general dentists in the United States. J Am Dent Assoc 2018; 149:372-381.e1. [PMID: 29703279 PMCID: PMC5995471 DOI: 10.1016/j.adaj.2017.11.034] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 11/27/2017] [Accepted: 11/28/2017] [Indexed: 01/21/2023]
Abstract
BACKGROUND The purpose of this study was to assess dental antibiotic prescribing trends over time, to quantify the number and types of antibiotics dentists prescribe inappropriately, and to estimate the excess health care costs of inappropriate antibiotic prescribing with the use of a large cohort of general dentists in the United States. METHODS We used a quasi-Poisson regression model to analyze antibiotic prescriptions trends by general dentists between January 1, 2013, and December 31, 2015, with the use of data from Express Scripts Holding Company, a large pharmacy benefits manager. We evaluated antibiotic duration and appropriateness for general dentists. Appropriateness was evaluated by reviewing the antibiotic prescribed and the duration of the prescription. RESULTS Overall, the number and rate of antibiotic prescriptions prescribed by general dentists remained stable in our cohort. During the 3-year study period, approximately 14% of antibiotic prescriptions were deemed inappropriate, based on the antibiotic prescribed, antibiotic treatment duration, or both indicators. The quasi-Poisson regression model, which adjusted for number of beneficiaries covered, revealed a small but statistically significant decrease in the monthly rate of inappropriate antibiotic prescriptions by 0.32% (95% confidence interval, 0.14% to 0.50%; P = .001). CONCLUSIONS Overall antibiotic prescribing practices among general dentists in this cohort remained stable over time. The rate of inappropriate antibiotic prescriptions by general dentists decreased slightly over time. PRACTICAL IMPLICATIONS From these authors' definition of appropriate antibiotic prescription choice and duration, inappropriate antibiotic prescriptions are common (14% of all antibiotic prescriptions) among general dentists. Further analyses with the use of chart review, administrative data sets, or other approaches are needed to better evaluate antibiotic prescribing practices among dentists.
Collapse
Affiliation(s)
| | - Qianxi Feng
- Division of Infectious Diseases, Washington University in St.
Louis
- Brown School of Social Work and Public Health, Washington University
in St. Louis
| | - Kyle Warren
- Division of Infectious Diseases, Washington University in St.
Louis
- University of Missouri School of Medicine
| | | | | | | | | | - Kevin Hsueh
- Division of Infectious Diseases, Washington University in St.
Louis
| | | | | |
Collapse
|