Outpatient Antibiotic Prescribing Patterns for Adult End-Stage Renal Disease Patients in New York State.

BACKGROUND: Infections are important complications of end-stage renal disease (ESRD) with few studies having investigated oral antibiotic use. Inappropriate antibiotic prescribing can contribute to multidrug-resistant organisms and Clostridioides difficile infections seen in ESRD. This study investigates antibiotic prescribing practices in ESRD across New York State (NYS). METHODS: Retrospective case-control study from 2016 to 2017 of NYS ESRD and non-ESRD patients analyzing Medicare part B billing codes, 7 days before and 3 days after part D claims. Frequencies of each infection, each antibiotic, dosages, and the antibiotics associated with infections were assessed using χ 2 analysis. A NYS small dialysis organization comprising approximately 2200 patients was also analyzed. Outcomes measured were the frequencies of infections and of each antibiotic prescribed. Incidence measures included antibiotics per 1000 and individuals receiving antibiotics per 1000. RESULTS: A total of 48 100 infections were treated in 35 369 ESRD patients and 2 544 443 infections treated in 3 777 314 non-ESRD patients. ESRD patients were younger, male, and African American. ESRD and non-ESRD patients receiving antibiotics was 520.29/1000 and 296.48/1000, respectively (P < .05). The prescription incidence was 1359.95/1000 ESRD vs 673.61/1000 non-ESRD patients. In 36%, trimethoprim-sulfamethoxazole dosage was elevated by current ESRD guidelines. Top infectious categories included nonspecific symptoms, skin, and respiratory for ESRD; and respiratory, nonspecific symptoms, and genitourinary in non-ESRD. CONCLUSIONS: This study identifies issues with appropriate antibiotic usage stressing the importance of antibiotic education to nephrologist and nonnephrologist providers. It provides support for outpatient antibiotic stewardship programs.

Antibiotic Prescribing in New York State Medicare Part B Beneficiaries Diagnosed With Cystitis Between 2016 and 2017.

BACKGROUND: Statewide tracking and reporting is an outpatient antimicrobial stewardship tool that may be useful for many stakeholders. However, to date, these evaluations have been limited. This study aimed to track and report outpatient antibiotic prescribing in Medicare Part B enrollees diagnosed with cystitis in the outpatient setting. METHODS: This was a retrospective, cohort study of Medicare Part B enrollees in New York State. Inclusion criteria include outpatient visit in 2016 or 2017, cystitis diagnosis code, and oral antibiotic prescription ≤3 days after diagnosis of cystitis. Antibiotics were categorized as first-line, oral ß-lactams, fluoroquinolones, or other per Infectious Diseases Society of America acute uncomplicated cystitis guidelines. Data were stratified by sex. Annual prescriptions proportions were compared using χ 2 test or Fisher's exact test as appropriate. RESULTS: A total of 50 658 prescriptions were included. For females' prescriptions, first line increased (41.5% vs 43.8%, P < .0001), oral ß-lactams increased (17.8% vs 20.5%, P < .0001), fluoroquinolones decreased (34.1% vs 29.1%, P < .0001), and other increased (6.5% vs 6.6%, P = .76) in 2017. For males' prescriptions, first line increased (25.2% vs 26.7%, P = .11), oral ß-lactams increased (23.1% vs 26.2%, P = .0003), fluoroquinolones decreased (44.0% vs 39.3%, P < .0001), and other remained unchanged (7.8% vs 7.8%, P = .92) in 2017. CONCLUSIONS: Guideline concordant therapy prescribing for cystitis increased among Medicare Part B beneficiaries in New York State between 2016 and 2017. However, there was still a high prevalence of fluoroquinolone prescribing. These data highlight the need for additional outpatient antimicrobial stewardship efforts in New York State.

Antimicrobial Susceptibility Trends Observed in Urinary Pathogens Obtained From New York State.

International guidelines recommend using local susceptibility data to direct empiric therapy for acute uncomplicated cystitis. We evaluated outpatient urinary isolate susceptibility trends in New York State. Nitrofurantoin had the lowest resistance prevalence whereas trimethoprim-sulfamethoxazole and fluoroquinolones had higher prevalences. This study highlights the need for local outpatient antimicrobial stewardship programs.

Multi-site heart disease risk assessment service provided by pharmacy students.

OBJECTIVE: To evaluate a pharmacy student service focused on patient coronary heart disease (CHD) risk assessment. DESIGN: Fourth-year pharmacy students offered a CHD risk assessment service at 5 physicians' offices as part of ambulatory care advanced pharmacy practice experience (APPE). Patient acceptance of the service was assessed using a satisfaction survey instrument. ASSESSMENT: Fifty-seven students educated 311 patients about CHD risk. Of the 258 patients who completed the satisfaction survey, 245 (95%) reported that the service was helpful in understanding CHD risk, and 79 (31%) learned of a personal CHD risk factor of which they were not previously aware. Student knowledge was assessed using a multiple-choice pretest and posttest focused on CHD knowledge recall. Students' test scores improved from pretest to posttest (mean 51.6 % +/- 1.1 vs. 64. 8% +/- 1.0. respectively; p = 0.01). CONCLUSIONS: A CHD risk assessment service provided by APPE students in ambulatory care settings was educational for both students and patients.

Effectiveness of a medication reconciliation project conducted by PharmD students.

OBJECTIVES: This study evaluated the effectiveness of a medication reconciliation program conducted by doctor of pharmacy (PharmD) students during an advanced pharmacy practice experience. METHODS: Patients admitted to medicine or surgery units at 3 hospitals were included. Students were instructed to interview each patient to obtain a medication history, reconcile this list with the medical chart, and identify and solve drug-related problems. RESULTS: Eleven students reconciled medications for 330 patients over 10 months and identified 922 discrepancies. The median number of discrepancies found per patient was 2, and no discrepancies were found in 25% of the cases. In cases in which discrepancies were identified, a greater number of medications had been prescribed for the patient (7.9 +/- 4.0 medications compared to 5.4 +/- 3.9 medications; p < 0.05). The students completed 59 interventions. Differences were found in the numbers of discrepancies and drug-related problems that different students at different sites identified (p < 0.05). CONCLUSIONS: Pharmacy students provided a valuable service to 3 community hospitals. The students improved the quality of patient care by identifying and solving significant drug-related problems, identifying drug allergy information, and resolving home and admission medication discrepancies.

Relationship between obesity and cardiovascular risk factors: findings from a multi-state screening project in the United States.

OBJECTIVE: This study examined the impact of body mass index (BMI) category on cardiovascular risk factors such as systolic blood pressure (SBP), high-density lipoprotein (HDL) and total cholesterol (TC). METHODS: Voluntary coronary heart disease (CHD) risk screenings were conducted in 18 states. A mobile screenings unit and team were used to collect data. Respondents were classified as per World Health Organization (WHO) guidelines based on BMI as non-overweight (BMI < or = 25); overweight (BMI > 25 and < or = 30); obese (BMI > 30 and < or = 35); and severely obese (BMI > 35). Hierarchical multiple linear regression analyses were used to measure the impact of BMI on SBP, HDL, and TC after adjusting for age, race, gender, smoking, self-reported prevalence of hypertension and hyperlipidemia, presence of diabetes/CHD event. RESULTS: Of the 12573 screened, 36% were overweight, 16.9% were obese and 7.9% were severely obese. Diabetes and prior CHD event were reported in 5.8% and 12.5% of the respondents, respectively. Mean 10-years CHD risk scores were significantly higher in males (10.4 +/- 9.3) than females (3.2 +/- 4.8) (p < 0.001). Compared to non-overweight respondents, SBP increased by 13.2 mmHg for severely obese (p < 0.001); by 8.9 mmHg for obese (p < 0.001), and by 5.2 mmHg (p < 0.001) for overweight respondents, respectively. TC was 6.8 mg/dL higher in obese (p < 0.01) and 6.9 mg/dL higher in overweight respondents (p < 0.001) as compared to non-overweight respondents. As compared to non-obese respondents, HDL was 9.8 mg/dL lower in severely obese (p < 0.001), 7.6 mg/dL lower in obese (p < 0.001), and 4.6 mg/dL lower in overweight respondents (p < 0.001). CONCLUSIONS: Our results demonstrate a significant impact of increasing BMI category on the CHD risk factors of SBP and HDL in a Us population. These data illustrate the importance of weight reduction in cardiovascular health.

Cost advantage of voriconazole over amphotericin B deoxycholate for primary treatment of invasive aspergillosis.

STUDY OBJECTIVES: Using data from a published clinical trial, our objectives were to compare the cost advantage of voriconazole over amphotericin B deoxycholate (AmBd) for primary treatment of invasive aspergillosis and to determine the financial impact the findings would have in a real-world clinical setting. DESIGN: Pharmacoeconomic analysis. SETTING: University hospital. PATIENTS: Two hundred seventy-seven patients in the modified intent-to-treat population. MEASUREMENTS AND MAIN RESULTS: An analysis was performed of drug acquisition costs for all patients in the modified intent-to-treat population, which consisted of 144 patients in the voriconazole group and 133 in the AmBd group. The analysis included costs of initial drug therapy; conversion from intravenous to oral treatment for patients receiving voriconazole; and the types, dosages, and duration of other licensed [Food and Drug Administration-approved] antifungal therapy (OLAT) for up to three OLAT regimens/patient. Current drug costs for our university hospital were used for all calculations. Total voriconazole costs were $784,405 ($581,008 for initial therapy with voriconazole, $203,397 for OLAT) compared with $852,238 for AmBd ($31,677 for initial AmBd therapy, $820,561 for OLAT). Over the 12-week study period, the cost/patient was $961 less for patients whose initial treatment was voriconazole than for those whose initial treatment was AmBd. Other licensed antifungal therapy accounted for 26% and 96% of total drug costs for voriconazole and AmBd, respectively. Other licensed antifungal therapy was given to 36% of voriconazole-treated patients and 80% of AmBd-treated patients. CONCLUSION: These data demonstrate the importance of evaluating total drug costs when comparing treatment regimens and not just initial therapy. Initial therapy with voriconazole had a cost advantage over AmBd in total antifungal drug cost/patient.

Medication adherence and associated hemoglobin A1c in type 2 diabetes.

BACKGROUND: Tight blood glucose control has been correlated with a reduction in diabetes complications. Adherence to antidiabetic medications is crucial to achieving blood glucose control. OBJECTIVE: To assess the relationship between good glucose control [glycosylated hemoglobin (HbA1c) levels] and adherence to prescribed treatment in patients on a stable medication regimen for type 2 diabetes. METHODS: The Morisky survey, a 4-item questionnaire that predicts patient medication-taking behavior, was used to assess adherence in 301 patients. The relationship of HbA1c to Morisky score was evaluated, controlling for other variables related to patient demographics and clinical characteristics. Data were analyzed using a general linear model on log (HbA1c). RESULTS: Unadjusted mean HbA1c values (capped at 14.0%) for patients with Morisky scores of 0 or 1, 2, 3, and 4 were 8.92%, 8.67%, 7.74%, and 7.60%, respectively. Of all patients, 13.0%, 14.0%, 24.3%, and 48.8% had scores of 0 or 1, 2, 3, and 4, respectively. Good adherence (Morisky score > or = 3) was associated with a 10% lower total HbA1c (p = 0.0003) adjusted for all other factors in the model. Duration of diabetes (5-10 y) and presence of diabetes complications were also significantly associated with HbA1c (p = 0.026 and 0.002, respectively). Adherence was poor in 27% of patients. CONCLUSIONS: This study found that patients with a higher score on the Morisky scale had a lower associated HbA1c measurement. The Morisky score may be an efficient tool for identifying patients with poor medication-taking behavior who can then be targeted for directed adherence counseling services.

Relationship between fluoroquinolone use and changes in susceptibility to fluoroquinolones of selected pathogens in 10 United States teaching hospitals, 1991-2000.

We retrospectively examined the relationship between fluoroquinolone use and the susceptibilities of 11 bacterial pathogens to fluoroquinolones in 10 US teaching hospitals from 1991 through 2000. Statistical significance was determined by 2-way analysis of variance, with the number of isolates tested each year as a weighting factor. The analysis of baseline-to-end point change in the percentage of susceptibility and the slope of the regression line (trend line) for logit percentage of susceptibility showed that the overall percentage of susceptibility to fluoroquinolones decreased significantly during the study period (P<.05) and that change in percentage of susceptibility was significantly related to change in fluoroquinolone use (P<.05). Particularly notable were the decreases in the susceptibilities of Pseudomonas aeruginosa, Proteus mirabilis, and Escherichia coli (decreases of 25.1%, 11.9%, and 6.8%, respectively).