Empirical antimicrobial prescribing for pyelonephritis in patients discharged from 15 US Emergency Departments: an opportunity for improvement.

BACKGROUND: Urinary tract infections (UTIs) are commonly treated in the emergency department (ED), and unfortunately, resistance to first-line agents is increasing. OBJECTIVES: To characterize treatment of pyelonephritis in a nationally representative sample of ED patients and to identify patient- and treatment-specific factors associated with receiving initial inactive antibiotics. METHODS: We conducted a multicentre, observational cohort study utilizing the Emergency Medicine PHARMacotherapy Research NETwork (EMPHARM-NET), comprising 15 geographically diverse US EDs. All patients ≥18 years of age with a diagnosis of pyelonephritis between 2018 and 2020 were included. The primary endpoint was the proportion of patients who received initial inactive empirical antibiotic therapy and to identify predictive factors of inactive antibiotic therapy. RESULTS: Of the 3714 patients evaluated, 223 had culture-positive pyelonephritis. Median patient age was 50.1 years and patients were mostly female (78.3%). Overall, 40.4% of patients received an IV antibiotic, most commonly ceftriaxone (86.7%). The most frequently prescribed antibiotics were cefalexin (31.8%), ciprofloxacin (14.3%), cefdinir (13.5%) and trimethoprim/sulfamethoxazole (12.6%). Overall, 10.3% of patients received initial inactive therapy. After adjustment in a multivariable analysis, long-acting IV antibiotic was predictive of inactive therapy (OR 0.23, 95% CI 0.07-0.83). CONCLUSIONS: In our prospective, multicentre observational study, we found that only 40.4% of patients with pyelonephritis received empirical IV antibiotics in the ED, contributing to inactive therapy. Receipt of long-acting IV antibiotics was independently associated with a decreased rate of initial inactive therapy. This reinforces guideline recommendations to administer long-acting IV antibiotics empirically in the ED upon suspicion of pyelonephritis.

Vancomycin Versus Metronidazole for Nonsevere Clostridioides difficile Infection: Are the Data Adequate to Change Practice?

Objective: To compare oral metronidazole and vancomycin for the treatment of mild-to-moderate Clostridioides difficile infection (mmCDI). Data Sources: A MEDLINE literature search (inception to November 2018) was performed using the search terms metronidazole, vancomycin, and Clostridium/Clostridioides difficile. Additional references were identified from a review of literature citations. Study Selection and Data Extraction: All English-language clinical studies (interventional and observational), meta-analyses, and cost-effectiveness analyses comparing the efficacy of metronidazole and vancomycin for mmCDI were evaluated. Data Synthesis: Nine clinical studies, 5 meta-analyses, and 1 cost-effectiveness analysis provided comparative data for metronidazole and vancomycin for the treatment of mmCDI. Improved treatment response with vancomycin as compared with metronidazole in adults with mmCDI reached statistical significance in a few studies; albeit, most studies and pooled analyses have results that numerically favor vancomycin. Furthermore, the cost per case treated appears to be lower with vancomycin compared with metronidazole based on data from hospitalized patients. Relevance to Patient Care and Clinical Practice: Recent updates to national guidelines now give preference to vancomycin over metronidazole for mmCDI; however, this has been a source of controversy. This review provides an appraisal of direct and indirect comparisons of oral metronidazole and vancomycin for mmCDI, including recent literature published after the release of current guidelines. Conclusions: The available outcome data suggesting that vancomycin is more effective than metronidazole, combined with the more favorable pharmacokinetics, safety, and tolerability profile of vancomycin, provide adequate clinical rationale for the preferential use of this agent for the treatment of mmCDI.

Simplified Aztreonam Dosing in Patients with End-Stage Renal Disease: Results of a Monte Carlo Simulation.

The manufacturer-recommended aztreonam dosing for patients with creatinine clearance values of <10 ml/min/1.73 m2 is complex. It is not known whether simpler posthemodialysis dosing administered once daily or thrice weekly can reliably achieve pharmacodynamic goals. We found that 1 or 2 g administered once daily after hemodialysis had >90% probability of target attainment up to MICs of 4 or 8 mg/liter, respectively. Thrice-weekly dosing should generally be avoided, except in nonsevere infections with MICs of ≤0.5 mg/liter.

Prevalence of a Cefazolin Inoculum Effect Associated with blaZ Gene Types among Methicillin-Susceptible Staphylococcus aureus Isolates from Four Major Medical Centers in Chicago.

The efficacy of cefazolin with high-inoculum methicillin-susceptible Staphylococcus aureus (MSSA) infections remains in question due to therapeutic failure inferred as being due to an inoculum effect (InE). This study investigated the local prevalence of a cefazolin InE (CInE) and its association with staphylococcal blaZ gene types among MSSA isolates in the Chicago area. Four medical centers in Chicago, IL, contributed MSSA isolates. Cefazolin MICs (C-MIC) were determined at 24 h by the broth microdilution method using a standard inoculum (SI; 5 × 105 CFU/ml) and a high inoculum (HI; 5 × 107 CFU/ml). The CInE was defined as (i) a ≥4-fold increase in C-MIC between SI and HI and/or (ii) a pronounced CInE, i.e., a nonsusceptible C-MIC of ≥16 µg/ml at HI. PCR was used to amplify the blaZ gene, followed by agarose gel electrophoresis and sequencing to determine the gene type. Approximately 269 MSSA isolates were included. All but one isolate were susceptible to cefazolin at SI, and 97% remained susceptible at HI. A total of 196 isolates (73%) were blaZ positive, with the blaZ types led by gene type C (40%). CInE was seen in 45 blaZ-positive isolates (23%), with 44 (22%) presenting a ≥4-fold increase in C-MIC (SI to HI) and 5 (3%) a pronounced CInE. Four of the five met both definitions of CInE, two of which expressed the type A gene. The prevalence of a pronounced CInE associated with the type A blaZ gene from MSSA isolates in Chicago is low. Our predilection for cefazolin use, even early in the management of hospitalized MSSA infections, is tenable.

Intravenous Push Administration of Antibiotics: Literature and Considerations.

Intravenous (IV) push administration can provide clinical and practical advantages over longer IV infusions in multiple clinical scenarios, including in the emergency department, in fluid-restricted patients, and when supplies of diluents are limited. In these settings, conversion to IV push administration may provide a solution. This review compiles available data on IV push administration of antibiotics in adults, including preparation, stability, and administration instructions. Prescribing information, multiple tertiary drug resources, and primary literature were consulted to compile relevant data. Several antibiotics are Food and Drug Administration-approved for IV push administration, including many beta-lactams. In addition, cefepime, ceftriaxone, ertapenem, gentamicin, and tobramycin have primary literature data to support IV push administration. While amikacin, ciprofloxacin, imipenem/cilastatin, and metronidazole have limited primary literature data on IV push administration, available data do not support that route. In addition, a discussion on practical considerations, such as IV push best practices and pharmacodynamic considerations, is provided.

The Effect of a Piperacillin/Tazobactam Shortage on Antimicrobial Prescribing and Clostridium difficile Risk in 88 US Medical Centers.

BACKGROUND: Anti-infective shortages are a pervasive problem in the United States. The objective of this study was to identify any associations between changes in prescribing of antibiotics that have a high risk for CDI during a piperacillin/tazobactam (PIP/TAZO) shortage and hospital-onset Clostridium difficile infection (HO-CDI) risk in 88 US medical centers. METHODS: We analyzed electronically captured microbiology and antibiotic use data from a network of US hospitals from July 2014 through June 2016. The primary outcome was HO-CDI rate and the secondary outcome was changes in antibiotic usage. We fit a Poisson model to estimate the risk of HO-CDI associated with PIP/TAZO shortage that were associated with increased high-risk antibiotic use while controlling for hospital characteristics. RESULTS: A total of 88 hospitals experienced PIP/TAZO shortage and 72 of them experienced a shift toward increased use of high-risk antibiotics during the shortage period. The adjusted relative risk (RR) of HO-CDI for hospitals experiencing a PIP/TAZO shortage was 1.03 (95% confidence interval [CI], .85-1.26; P = .73). The adjusted RR of HO-CDI for hospitals that both experienced a shortage and also showed a shift toward increased use of high-risk antibiotics was 1.30 (95% CI, 1.03-1.64; P < .05). CONCLUSIONS: Hospitals that experienced a PIP/TAZO shortage and responded to that shortage by shifting antibiotic usage toward antibiotics traditionally known to place patients at greater risk for CDI experienced greater HO-CDI rates; this highlights an important adverse effect of the PIP/TAZO shortage and the importance of antibiotic stewardship when mitigating drug shortages.

Oral Ribavirin for the Treatment of Noninfluenza Respiratory Viral Infections: A Systematic Review.

OBJECTIVE: To review clinical outcomes data for patients treated with oral ribavirin for noninfluenza respiratory viral infections (NIRVIs). DATA SOURCES: MEDLINE, EMBASE, and PubMed Central (1972 to June 1, 2015) were queried with the following search term combinations: "Oral" AND "ribavirin" AND ("respiratory syncytial virus" OR "metapneumovirus" OR "parainfluenza" OR "coronavirus" OR "rhinovirus" OR "enterovirus" OR "adenovirus"). STUDY SELECTION AND DATA EXTRACTION: Included studies must have characterized the clinical outcomes of a cohort of patients treated with oral ribavirin for symptomatic NIRVIs. Case reports and series with <5 cases, conference abstracts, and articles written in languages other than English were excluded. DATA SYNTHESIS: Of the 1256 unique reports, 15 met inclusion criteria: 12 retrospective, 3 prospective, and 3 comparative with untreated control groups. All studies except for 2 Middle East respiratory syndrome coronavirus (MERS-CoV) studies were in immunocompromised patients (9 malignancy/stem cell transplant, 4 lung transplant). The mortality rate ranged from 0% to 31% in malignancy/stem cell transplant recipients treated with oral ribavirin, and 1/108 (0.9%) ribavirin-treated lung transplant recipients died at 30 days. Three studies (one each for malignancy, lung transplant, and MERS-CoV) suggested a clinical outcomes benefit with oral ribavirin compared with supportive care alone; however, the nonrandomized design precludes efficacy determination. Hemolysis was the most common adverse reaction, occurring in 14% (54/375) of patients. Ribavirin was discontinued in 4% of patients secondary to adverse reactions. CONCLUSIONS: Oral ribavirin should be considered for the treatment of NIRVI in immunocompromised adults (malignancy/stem cell transplant or lung transplant) or adults with MERS-CoV.

Epidemiology and predictors of multidrug-resistant community-acquired and health care-associated pneumonia.

There are limited U.S. data describing the risk factors for multidrug-resistant organism (MDRO) isolation in community-acquired pneumonia (CAP) and health care-associated pneumonia (HCAP). However, concern for the presence of these pathogens drives the prescribing of empiric broad-spectrum antibiotics for CAP and HCAP. A retrospective study of all adults hospitalized with community-onset pneumonia (CAP and HCAP) at a large U.S. medical center from January 2010 to December 2011 was conducted. The objective was to ascertain the rate of pneumonia caused by MDROs and to evaluate whether HCAP is a risk factor for MDRO pneumonia. Univariate and propensity score-adjusted multivariate analyses were performed. A total of 521 patients (50.5% CAP and 49.5% HCAP) were included. The most common etiologies of pneumonia were primary viral and Streptococcus pneumoniae. MDROs were isolated in 20 (3.8%) patients overall, and MDROs occurred in 5.9% and 1.9% of HCAP and CAP patients, respectively. The presence of an MDRO was not associated with HCAP classification (odds ratio [OR]=1.95; 95% confidence interval [95% CI], 0.66 to 5.80; P=0.23) or with most of its individual components (hemodialysis, home infusion, home wound care, and ≥48-h hospitalization in the last 90 days). Independent predictors of MDRO included the following: Pseudomonas aeruginosa colonization/infection in the previous year (OR=7.43; 95% CI, 2.24 to 24.61; P<0.001), antimicrobial use in the previous 90 days (OR=2.90; 95% CI, 1.13 to 7.45; P=0.027), admission from a nursing home (OR=4.19; 95% CI, 1.55 to 11.31; P=0.005), and duration of hospitalization in the previous 90 or 180 days (P=0.013 and P=0.002, respectively). MDROs were uncommon in HCAP and CAP. HCAP did not predict MDRO isolation. Local etiology of community onset pneumonia and specific MDRO risk factors should be integrated into therapeutic decisions to prevent empirical overprescribing of antibiotics for methicillin-resistant Staphylococcus aureus (MRSA) and P. aeruginosa.

Antiretroviral medication prescribing errors are common with hospitalization of HIV-infected patients.

OBJECTIVES: Errors in prescribing antiretroviral therapy (ART) often occur with the hospitalization of HIV-infected patients. The rapid identification and prevention of errors may reduce patient harm and healthcare-associated costs. METHODS: A retrospective review of hospitalized HIV-infected patients was carried out between 1 January 2009 and 31 December 2011. Errors were documented as omission, underdose, overdose, duplicate therapy, incorrect scheduling and/or incorrect therapy. The time to error correction was recorded. Relative risks (RRs) were computed to evaluate patient characteristics and error rates. RESULTS: A total of 289 medication errors were identified in 146/416 admissions (35%). The most common was drug omission (69%). At an error rate of 31%, nucleoside reverse transcriptase inhibitors were associated with an increased risk of error when compared with protease inhibitors (RR 1.32; 95% CI 1.04-1.69) and co-formulated drugs (RR 1.59; 95% CI 1.19-2.09). Of the errors, 31% were corrected within the first 24 h, but over half (55%) were never remedied. Admissions with an omission error were 7.4 times more likely to have all errors corrected within 24 h than were admissions without an omission. Drug interactions with ART were detected on 51 occasions. For the study population (n = 177), an increased risk of admission error was observed for black (43%) compared with white (28%) individuals (RR 1.53; 95% CI 1.16-2.03) but no significant differences were observed between white patients and other minorities or between men and women. CONCLUSION: Errors in inpatient ART were common, and the majority were never detected. The most common errors involved omission of medication, and nucleoside reverse transcriptase inhibitors had the highest rate of prescribing error. Interventions to prevent and correct errors are urgently needed.

Cost evaluation of a nurse coordinated outpatient parenteral antimicrobial therapy (OPAT) program.

A structured, nurse-driven outpatient parenteral antimicrobial therapy (OPAT) program within an academic healthcare system was associated with reduced odds of 60-day unplanned OPAT readmissions and costs after hospital discharge. These findings may facilitate justifying additional resources for OPAT programs to improve care while decreasing costs.

Barriers and facilitators to guideline concordant dental antibiotic prescribing in the United States: A qualitative study of the National Dental PBRN.

OBJECTIVES: While factors contributing to dental antibiotic overprescribing have previously been described, previous work has lacked any theoretical behavior change framework that could guide future intervention development. The purpose of this study was to use an evidence-based conceptual model to identify barriers and facilitators of appropriate antibiotic prescribing by dentists as a guide for future interventions aimed at modifying antibiotic prescribing. METHODS: Semi-structured interviews were conducted with dentists from the National Dental Practice Based Research Network (PBRN) exploring patient and practice factors perceived to impact antibiotic prescribing. Audio-recorded telephone interviews were transcribed and independently coded by three researchers. Themes were organized around the COM-B model to inform prospective interventions. RESULTS: 73 of 104 dentists (70.1%) were interviewed. Most were general dentists (86.3%), male (65.7%), and white (69.9%). Coding identified three broad targets to support appropriate dental antibiotic prescribing among dentists: (1) increasing visibility and accessibility of guidelines, (2) providing additional guidance on antibiotic prescribing in dental scenarios without clear guidelines, and (3) education and communication skills-building focused on discussing appropriate antibiotic use with patients and physicians. CONCLUSIONS: The findings from our study are consistent with other studies focusing on antibiotic prescribing behavior in dentists. Understanding facilitators and barriers to dental antibiotic prescribing is necessary to inform targeted interventions to improve appropriate antibiotic prescribing. Future interventions should focus on implementing multimodal strategies to provide the necessary support for dentists to judiciously prescribe antibiotics.

A Multicenter Retrospective Study Evaluating Intravenous to Oral Antibiotic Stepdown for Uncomplicated Streptococcal Bacteremia.

Background: The purpose of this study was to compare the efficacy and safety of intravenous (IV) versus oral (PO) stepdown therapy for uncomplicated streptococcal bacteremia. Methods: This multicenter, retrospective study included adult patients with uncomplicated streptococcal bacteremia between 1 July 2019 and 1 July 2022. Patients who received IV therapy for the full treatment course were compared to patients who transitioned to PO therapy after initial IV therapy. The primary outcome was clinical success, defined as absence of infection recurrence, infection-related readmission, and infection-related mortality at 90 days. Secondary outcomes included microbiological success, length of stay (LOS), and IV line-associated complications. Results: Of 238 patients included, 47.1% received PO stepdown therapy. Clinical success occurred in 94.4% and 94.6% in the IV only and PO stepdown groups, respectively (P = .946). Patients who transitioned to PO therapy received a median duration of IV therapy of 3.9 days (interquartile range, 2.9-7.3 days). Line complications were more frequent in the IV only group, primarily driven by catheter-related infections (7.2% vs 0%, P = .002). LOS was significantly shorter in the PO stepdown group (5.5 vs 9.2 days, P < .001). Conclusions: Patients transitioned to PO antibiotics for uncomplicated streptococcal bacteremia had similar rates of clinical success compared to patients who received only IV therapy. With consideration of infectious source, severity of illness, and comorbidities, PO stepdown following initial IV antibiotics for uncomplicated streptococcal bacteremia in select patients is a reasonable approach that may result in decreased LOS and line-related complications.

Using higher doses to compensate for tubing residuals in extended-infusion piperacillin-tazobactam.

OBJECTIVE: To mathematically assess drug losses due to infusion line residuals and evaluate methods to compensate for drug loss due to residual volumes in intravenous pump tubing. DATA SOURCES: Literature was accessed through Ovid MEDLINE (1996-February 2013), using combinations of the search terms tubing residuals, residual volume, residual medication, intravenous infusions, intravenous injections, piperacillin, piperacillin-tazobactam, ß-lactams, equipment design, infusion pumps, extended infusion, extended administration, and prolonged infusion. In addition, select reference citations from publications identified were reviewed. STUDY SELECTION AND DATA EXTRACTION: All articles that involved extended-infusion piperacillin-tazobactam implementation strategies were included in the review. DATA SYNTHESIS: Infusion pump characteristics and tubing residuals can affect extended-infusion piperacillin-tazobactam dosing strategies. Two studies addressing tubing residuals were identified. Both studies recommended increasing infusion volumes to compensate for tubing residuals. One study also recommended decreasing infusion-line dead space by using alternative infusion pump systems. Study calculations suggest that higher doses of piperacillin-tazobactam may be used to account for medication left in tubing residuals if alternative infusion pump systems cannot be obtained, and increased infusion volumes are not an option. CONCLUSIONS: Extended-infusion piperacillin-tazobactam has been used as a method of maximizing pharmacodynamic target attainment. Use of higher doses of piperacillin-tazobactam may be a reasonable method to compensate for drug loss due to residual volumes in large-bore intravenous pump tubing.

Role of religious attendance and identity conflict in psychological well-being.

A sample of individuals who identified as gay or lesbian were administered measures of church attendance, their religious organization's view of homosexuality, perceived conflict between religious faith identity and sexual orientation identity, social support, depression, and generalized anxiety. Among participants who rated their church as rejecting of homosexuality, greater frequency of attendance was related to a higher incidence of GAD symptoms, but not depression. No correlation was found for those attending accepting faith communities. Those who attend rejecting faith communities attended services less often, experienced greater identity conflict, and reported significantly less social support than those of the Accepted group. Regression analyses indicated that identity conflict and social support did not fully account for the relationship between attendance and GAD symptoms. Overall, findings from the current study support previous suggestions that participation in conservative or rejecting religious communities may adversely affect the emotional well-being of GL individuals.

Evaluation of Outpatient Antibiotic Prescribing for Urinary Tract Infection in Pediatric Patients Ages 2 Months to 18 Years.

OBJECTIVE: To characterize the diagnosis and management of urinary tract infection (UTI) in pediatric patients at the University of Illinois Hospital and Health Sciences System (UIH), with an emphasis on antibiotic prescribing; in addition, to characterize pediatric uropathogen patterns to help guide future empiric therapy choices. METHODS: We used a retrospective, descriptive study of pediatric patients ages 2 months to ≤18 years seen at the UIH emergency department or clinic from January 1, 2014, to August 31, 2018, with ICD-9 or ICD-10 discharge diagnosis of UTI. Data collected included presenting symptoms, urinalysis, details of antibiotic regimens, urine culture, and susceptibility results. RESULTS: Of the 207 patients included, the median age was 5.7 years (IQR, 3.2-9.4), and 183 patients (88.4%) were female. Common symptoms included dysuria (57%) and fever (37%). Empiric antibiotics were p-rescribed in 96.1% of cases, most commonly cefdinir (42%), cephalexin (22%), and sulfamethoxazole-trimethoprim (14%). Urine cultures were collected in 161 patients (77.8%), with 81 growing >50,000 colony-forming units bacteria. Escherichia coli was the most commonly isolated organism (82.1%), showing susceptibility to third-generation cephalosporins (97%), nitrofurantoin (95%), and sulfamethoxazole-trimethoprim (84%). Although 25 urine cultures showed no growth, antibiotics were discontinued in only 4 cases. CONCLUSIONS: Pediatric patients with UTI symptoms were often empirically prescribed cefdinir, possibly an unnecessarily broad choice because many E coli isolates were susceptible to narrower agents. Both urinalysis and urine cultures should be obtained during the diagnostic evaluation of UTI, with better follow-up of negative cultures to potentially discontinue antibiotics. This study highlights areas for improvement in the diagnosis, treatment, and antimicrobial stewardship in pediatric UTI.

Reporting behaviors and perceptions toward the National Healthcare Safety Network antimicrobial use (AU) and antimicrobial resistance (AR) modules.

OBJECTIVES: To identify characteristics of US health systems and end users that report antimicrobial use and resistance (AUR) data, to determine how NHSN AUR data are used by hospitals and health systems and end users, and to identify barriers to AUR reporting. DESIGN: An anonymous survey was sent to Society of Infectious Diseases Pharmacists (SIDP) and Society for Healthcare Epidemiology of America (SHEA) Research Network members. METHODS: Data were collected via Survey Monkey from January 21 to February 21, 2020. Respondent and hospital data were analyzed using descriptive statistics. RESULTS: We received responses from 238 individuals across 43 US states. Respondents were primarily pharmacists (84%), from urban areas, (44%), from nonprofit medical centers (81%), and from hospitals with >250 beds (72%). Also, 62% reported data to the AU module and 19% reported data to the AR module. Use of software for local AU or AR tracking was associated with increased reporting to the AU module (19% vs 64%) and the AR module (2% vs 30%) (P < .001 each). Only 36% of those reporting data to the AU module used NHSN AUR data analysis tools regularly and only 9% reported data to the AR module regularly. Technical challenges and time and/or salary support were the most common barriers to AUR participation cited by all respondents. Among those not reporting AUR data, increased local expectations to report and better software solutions were the most commonly identified solutions to increase AUR reporting. CONCLUSIONS: Efforts to increase AUR reporting should focus on software solutions and salary support for data-entry activities. Increasing expectations to report may incentivize local resource allocation to improve AUR reporting rates.

Decreased hospital readmissions after programmatic strengthening of an outpatient parenteral antimicrobial therapy (OPAT) program.

Objective: To determine whether a structured OPAT program supervised by an infectious disease physician and led by an OPAT nurse decreased hospital readmission rates and OPAT-related complications and whether it affected clinical cure. We also evaluated predictors of readmission while receiving OPAT. Patients: A convenience sample of 428 patients admitted to a tertiary-care hospital in Chicago, Illinois, with infections requiring intravenous antibiotic therapy after hospital discharge. Methods: In this retrospective, quasi-experimental study, we compared patients discharged on intravenous antimicrobials from an OPAT program before and after implementation of a structured ID physician and nurse-led OPAT program. The preintervention group consisted of patients discharged on OPAT managed by individual physicians without central program oversight or nurse care coordination. All-cause and OPAT-related readmissions were compared using the χ2 test. Factors associated with readmission for OPAT-related problems at a significance level of P < .10 in univariate analysis were eligible for testing in a forward, stepwise, multinomial, logistic regression to identify independent predictors of readmission. Results: In total, 428 patients were included in the study. Unplanned OPAT-related hospital readmissions decreased significantly after implementation of the structured OPAT program (17.8% vs 7%; P = .003). OPAT-related readmission reasons included infection recurrence or progression (53%), adverse drug reaction (26%), or line-associated issues (21%). Independent predictors of hospital readmission due to OPAT-related events included vancomycin administration and longer length of outpatient therapy. Clinical cure increased from 69.8% before the intervention to 94.9% after the intervention (P < .001). Conclusion: A structured ID physician and nurse-led OPAT program was associated with a decrease in OPAT-related readmissions and improved clinical cure.

Changes in antibiotic prescribing by dentists in the United States, 2012-2019.

OBJECTIVES: Dentists prescribe 10% of all outpatient antibiotics in the United States and are the top specialty prescriber. Data on current antibiotic prescribing trends are scarce. Therefore, we evaluated trends in antibiotic prescribing rates by dentists, and we further assessed whether these trends differed by agent, specialty, and by patient characteristics. DESIGN: Retrospective study of dental antibiotic prescribing included data from the IQVIA Longitudinal Prescription Data set from January 1, 2012 to December 31, 2019. METHODS: The change in the dentist prescribing rate and mean days' supply were evaluated using linear regression models. RESULTS: Dentists wrote >216 million antibiotic prescriptions between 2012 and 2019. The annual dental antibiotic prescribing rate remained steady over time (P = .5915). However, the dental prescribing rate (antibiotic prescriptions per 1,000 dentists) increased in the Northeast (by 1,313 antibiotics per 1,000 dentists per year), among oral and maxillofacial surgeons (n = 13,054), prosthodontists (n = 2,381), endodontists (n = 2,255), periodontists (n = 1,961), and for amoxicillin (n = 2,562; P < .04 for all). The mean days' supply significantly decreased over the study period by 0.023 days per 1,000 dentists per year (P < .001). CONCLUSIONS: From 2012 to 2019, dental prescribing rates for antibiotics remained unchanged, despite decreases in antibiotic prescribing nationally and changes in guidelines during the study period. However, mean days' supply decreased over time. Dental specialties, such as oral and maxillofacial surgeons, had the highest prescribing rate with increases over time. Antibiotic stewardship efforts to improve unnecessary prescribing by dentists and targeting dental specialists may decrease overall antibiotic prescribing rates by dentists.

The impact of anti-infective drug shortages on hospitals in the United States: trends and causes.

Anti-infective shortages pose significant logistical and clinical challenges to hospitals and may be considered a public health emergency. Anti-infectives often represent irreplaceable life-saving treatments. Furthermore, few new agents are available to treat increasingly prevalent multidrug-resistant pathogens. Frequent anti-infective shortages have substantially altered patient care and may lead to inferior patient outcomes. Because many of the shortages stem from problems with manufacturing and distribution, federal legislation has been introduced but not yet enacted to provide oversight for the adequate supply of critical medications. At the local level, hospitals should develop strategies to anticipate the impact and extent of shortages, to identify therapeutic alternatives, and to mitigate potential adverse outcomes. Here we describe the scope of recent anti-infective shortages in the United States and explore the reasons for inadequate drug supply.

The impact of attention on social functioning in survivors of pediatric acute lymphoblastic leukemia and brain tumors.

BACKGROUND: The cognitive late effects experienced by many survivors of pediatric acute lymphoblastic leukemia (ALL) and brain tumors are well-established. The most commonly reported deficit is difficulty with attention. Problems with social functioning have also been identified, but their relationship with cognitive functioning is not well understood. This multi-site, cross-sectional study aimed to examine the impact of attention on social functioning. PROCEDURE: Four hundred sixty nine survivors of ALL and brain tumors (55% ALL; 57% male) completed study procedures, including parent- and teacher-report measures of attention (Conners' Rating Scales, Revised) and parent-report of social functioning [Social Skills Rating System (SSRS)] as part of their screening evaluation for a large clinical trial. Survivors were 12.1 years of age and 4.9 years from the end of treatment at the time of study. RESULTS: Results revealed that survivors' parent-reported attention problems were uniquely associated with their social functioning, relative to known demographic- and treatment-related risk factors. Teacher-reported attention problems, in contrast, were not, despite a significant correlation between the two. Deficits in intelligence and female gender were also significantly associated with poor social functioning. CONCLUSIONS: Attention problems uniquely impact difficulties with social functioning in survivors of pediatric cancer. Future studies will need to further examine the relationship between attention and social functioning in survivors, particularly when assessed by teacher report. Pediatr Blood Cancer 2012; 59: 1290-1295. © 2012 Wiley Periodicals, Inc.