Risk of Tendon Injury in Patients Treated With Fluoroquinolone (FQ) Versus Non-Fluoroquinolone Antibiotics for Community-Acquired Pneumonia (CAP).

BACKGROUND: Fluoroquinolones (FQs) are associated with increased risk of tendon injury but comparative risk versus other antibiotic options for the same indication has yet to be evaluated. OBJECTIVE: Describe the incidence (relative risk) of any tendon injury in patients receiving FQ compared with other (non-FQs) antibiotics for treatment of community-acquired pneumonia (CAP). METHODS: A retrospective propensity score weighted cohort study was performed to evaluate the association between FQ antibiotics and tendon injury risk at 2 time points (within 1 month and within 6 months of use) compared with non-FQ regimens for treatment of CAP. The evaluation was performed using the CCAE (MarketScan Commercial Claims and Encounters) and COB (Medicare Supplemental and Coordination of Benefits) databases from 2014 to 2020. Patients with ICD (International Classification of Diseases) 9/10 coding for outpatient pneumonia who were >18 years and without history of tendon injury were included. Patients with history of tendon injury, who received multiple antibiotic therapies for recurrent pneumonia, or who received both FQ and non-FQ regimens during the study period were excluded. Propensity score weighting was used to adjust for selection bias due to contributing risk factors, including demographics (age, sex), comorbidities (diabetes mellitus, chronic kidney disease), and concurrent medications (corticosteroids). RESULTS: At 1 month, the odds of tendon injury were estimated to be significantly higher (41.9%) in patients receiving FQs compared with those receiving a non-FQ-based regimen (odds ratio [OR] = 1.419, 95% confidence interval [CI] = [1.188-1.698]). The odds of tendon injury were also estimated to be higher (OR = 1.067, 95% CI = [0.975-1.173]) in the FQ population within 180 days, but this effect was not statistically significant. The most frequent sites of tendon injuries were rotator cuff, shoulder, and patellar tendon. CONCLUSIONS AND RELEVANCE: Prescribers should recognize the risk of tendon injury within 1 month of FQ use when considering treatment regimens for CAP and use alternative options with lower risk whenever possible.

Resistance of Escherichia coli urinary isolates in ED-treated patients from a community hospital.

PURPOSE: The purpose of this study is to provide resistance data for Escherichia coli isolates causing urinary tract infections in emergency department (ED) patients not requiring admission and explore if differences between this subpopulation and the hospital antibiogram exist. Differences between community-acquired urinary tract infection (CA-UTI) and health care-associated (HA-UTI) subgroups were also investigated. METHODS: Patients with a positive urine culture treated and discharged from the ED of a 200-bed community hospital were reviewed. Patients with urinary isolates of more than 100000 colony-forming unit/mL and documented intention to treat were included. Patients who required admission, were pregnant, less than the age of 18 years, or who had a positive culture but without any evidence of intention to treat were excluded. Only the initial visit was included for patients who returned to the ED within 7 days. RESULTS: Overall, 308 visits were screened, and 217 were included. Of these, 78.3% were CA-UTI, and 21.7% were HA-UTI. Females comprised 88.5% of all patients. E coli was the most common pathogen overall and in both subgroups. E coli resistance to levofloxacin was 13.5% overall, 9.2% for CA-UTI, and 38.5% for HA-UTI compared with 27% on the hospital antibiogram. E coli resistance to sulfamethoxazole/trimethoprim was 26.9% overall, 25.2% for CA-UTI, and 34.6% for HA-UTI vs 26% on the antibiogram. CONCLUSIONS: E coli susceptibility for ED patients not requiring admission may not be accurately represented by hospital antibiograms that contain culture data from various patient types, sites of infection, or patients with varying illness severity. Separation of the ED population into CA-UTI and HA-UTI subgroups may be helpful when selecting empiric antibiotic therapy.

Community-acquired pneumonia with risk for drug-resistant pathogens.

BACKGROUND: Pneumonia is a leading infectious cause of morbidity and mortality in the United States. The Infectious Disease Society of America (IDSA) and American Thoracic Society (ATS) have published treatment guidelines for community-acquired pneumonia (CAP) based upon the site of acquisition and specific pathogen risk. The literature demonstrates improved outcomes with guideline-concordant empiric therapy. A subset of patients with CAP has risk factors for drug-resistant pathogens (DRPs). IDSA/ATS treatment guidelines do not provide clear recommendations for empiric treatment, and clinical studies have not provided descriptive data for this group. METHODS: A retrospective chart review of all admissions between January 1, 2008 and April 19, 2009 with an International Classification of Diseases-9 code and physician-documented diagnosis of pneumonia at two community hospitals were performed. IDSA pneumonia type and presence of risk factors for DRP were recorded for each patient, and the empiric antibiotic therapy received was evaluated. Admissions were excluded if immunosuppression or pregnancy was present. RESULTS: Of the 400 admissions reviewed, 343 patients were included. A total of 228 patients (71%) had CAP. Forty-three percent of patients with CAP had risk factors for DRP. Only 2% of this group received an antibiotic regimen with coverage of the specific DRP risk factor present. The most common DRPs not receiving coverage in this group were Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. P. aeruginosa and methicillin-resistant S. aureus occurred more commonly in culture-positive patients with CAP with DRP risk factors but did not achieve statistical significance. A larger sample size would be needed to determine whether this difference is significant. CONCLUSIONS: Risk factors for DRP occurred commonly in our CAP population. Patients with CAP with risk for DRP may be a distinct group who are without clear guidance on treatment. Future studies are needed to define the risk of DRP and the impact upon empiric therapy for patients with CAP.

Evaluation of pain management documentation.

OBJECTIVES: Accurate and consistent documentation of pain management, including patient responses regarding improvement in pain scores, is essential for improving patient care. The objective of the project was to evaluate the current prescribing patterns and to review the current documentation for opioid-managed, chronic pain patients in an academic continuity of care medicine clinic. METHODS: Retrospective data were extracted from currently managed adult, opioid patients to evaluate prescribing patterns and to review documentation processes. RESULTS: Results reveal inconsistent to absent documentation with most patients receiving prescriptions from multiple providers. Oxycodone/acetaminophen was the most frequently prescribed analgesic. CONCLUSION: The results of this evaluation highlight the opportunity for educational intervention and the development of a structured, institution-specific guideline for prescribing and documenting pain management.

Multicenter, Observational Cohort Study Evaluating Third-Generation Cephalosporin Therapy for Bloodstream Infections Secondary to Enterobacter, Serratia, and Citrobacter Species.

OBJECTIVES: There is debate on whether the use of third-generation cephalosporins (3GC) increases the risk of clinical failure in bloodstream infections (BSIs) caused by chromosomally-mediated AmpC-producing Enterobacterales (CAE). This study evaluates the impact of definitive 3GC therapy versus other antibiotics on clinical outcomes in BSIs due to Enterobacter, Serratia, or Citrobacter species. METHODS: This multicenter, retrospective cohort study evaluated adult hospitalized patients with BSIs secondary to Enterobacter, Serratia, or Citrobacter species from 1 January 2006 to 1 September 2014. Definitive 3GC therapy was compared to definitive therapy with other non-3GC antibiotics. Multivariable Cox proportional hazards regression evaluated the impact of definitive 3GC on overall treatment failure (OTF) as a composite of in-hospital mortality, 30-day hospital readmission, or 90-day reinfection. RESULTS: A total of 381 patients from 18 institutions in the southeastern United States were enrolled. Common sources of BSIs were the urinary tract and central venous catheters (78 (20.5%) patients each). Definitive 3GC therapy was utilized in 65 (17.1%) patients. OTF occurred in 22/65 patients (33.9%) in the definitive 3GC group vs. 94/316 (29.8%) in the non-3GC group (p = 0.51). Individual components of OTF were comparable between groups. Risk of OTF was comparable with definitive 3GC therapy vs. definitive non-3GC therapy (aHR 0.93, 95% CI 0.51-1.72) in multivariable Cox proportional hazards regression analysis. CONCLUSIONS: These outcomes suggest definitive 3GC therapy does not significantly alter the risk of poor clinical outcomes in the treatment of BSIs secondary to Enterobacter, Serratia, or Citrobacter species compared to other antimicrobial agents.

Evaluation of Video-enhanced Case-based Activities Guided by the Pharmacists' Patient Care Process.

Objective. To design and develop a series of technology-enhanced, case-based learning activities framed by the Pharmacists' Patient Care Process (PPCP), and to evaluate the impact of these activities on student perceptions and performance. Methods. A mixed methods approach was used to generate both quantitative and qualitative data. Survey and focus group interviews were used to analyze student perceptions. Performance on a pre- and post-assessment was used to measure the impact of PPCP case-based learning activities. Results. Students demonstrated positive attitudes overall towards the case-based learning activities. Themes emerged during focus group interviews regarding awareness of the PPCP, engagement in learning, and a desire for realistic experiences. Significant changes were observed for the pre- and post-assessment within the plan and follow-up parameters, as well as for the total score within each disease state. Conclusion. The use of technology-enhanced, case-based modules framed around a standardized patient care process resulted in positive student perceptions and improved scores on a patient case assessment. The PPCP may be a useful framework for case development to aid students in application of drug therapy knowledge.

A review of laxative therapies for treatment of chronic constipation in older adults.

BACKGROUND: Multiple studies have addressed the treatment of chronic constipation in adults in general; however, less guidance is available for treating this condition in older patients. OBJECTIVE: The aim of this paper was to review the effectiveness of laxatives for chronic constipation in the elderly. METHODS: Medline, Web of Science, international Pharmaceutical Abstracts, and the Cochrane database of Systematic Reviews were searched for english-language articles evaluating the treatment of chronic constipation in older individuals from the inception of the databases until October 2010. Search terms included constipation, treatment, laxative, elderly, and geriatric. Articles were excluded if the mean age was <65 years. RESULTS: Thirty-one trials were identified. These studies varied widely in terms of methodology, quality, sample size, efficacy end points, and duration. Mean stool frequency was 9.08 bowel movements per week with psyllium and 8.29 per week with calcium polycarbophil (P = 0.04). docusate sodium daily, docusate sodium q12h, and docusate calcium daily for 3 weeks produced a mean stool frequency of 1.95 bowel movements per week versus 1.50 for placebo (P = NS), 2.29 versus 1.76 (P = NS), and 2.83 versus 1.75 (P<0.02), respectively. Mean stool frequency with lactulose versus placebo was 0.7 and 0.5 bowel movements per day (P<0.02). in patients receiving polyethylene glycol or lactulose, mean stool frequency was 1.3 and 0.9 bowel movements per day (P = 0.005). in a study comparing senna plus a bulking agent with lactulose, mean stool frequency was 4.5 per week for the combination product versus 2.2 per week for lactulose (P<0.001). A study comparing sodium picosulfate with senna reported a mean stool frequency of 0.71 and 0.63 per day (P value not reported). Lubiprostone was associated with 5.69 spontaneous bowel movements per week versus 3.46 per week for placebo (P = 0.001). CONCLUSIONS: Higher-quality trials evaluating the treatment of constipation in older patients are needed to create a basis for more definitive recommendations in this population. The approach to older adults with constipation should be individualized.