COVID-19 Vaccine Policy Implementation and Differential Vaccine Uptake Trajectories in Chicago Communities.

BACKGROUND: Since the onset of the COVID-19 pandemic, multiple public health interventions have been implemented to respond to the rapidly evolving pandemic and community needs. This article describes the scope, timing, and impact of coordinated strategies for COVID-19 vaccine uptake in Chicago for the first year of vaccine distribution. METHODS: Using a series of interviews with public health officials and leaders of community-based organizations (CBOs) who participated in the implementation of the citywide COVID-19 vaccine outreach initiatives, we constructed a timeline of vaccine outreach initiatives. The timeline was matched to the vaccine uptake rates to explore the impact of the vaccine outreach initiatives by community area. Finally, we discussed the nature of policy initiatives and the level of vaccine uptake in relation to community characteristics. RESULTS: The Chicago Department of Public Health (CDPH) implemented myriad vaccine outreach strategies, including mass vaccination sites, improved access, and community-level vaccine campaigns. Protect Chicago+ was the primary vaccine outreach effort initiated by the CDPH, which identified 15 highly vulnerable community areas. More than 2.7 million (67%) Chicagoans completed the vaccine regimen by December 2021. Black (51.3%) Chicagoans were considerably less likely to be vaccinated than Asian (77.6%), White (69.8%), and Hispanic (63.6%) Chicago residents. In addition, there were significant spatial differences in the rate of COVID-19 vaccine completion: predominantly White and Hispanic communities, compared with Black communities, had higher rates of vaccine completion. CONCLUSIONS: The community outreach efforts to improve COVID-19 vaccine uptake in Chicago have shown the importance of community-engaged approaches in pandemic responses. Despite citywide efforts to build community infrastructure, Black communities had relatively lower levels of vaccine uptake than other communities. Broader social restructuring to mitigate disinvestment and residential segregation and to ameliorate medical mistrust will be needed to prepare for future pandemics and disasters.

Comparison of guideline concordant antibiotic prophylaxis in Veterans Affairs and non-Veterans Affairs dental settings among those with cardiac conditions or prosthetic joints.

BACKGROUND: No research has been conducted to assess whether antibiotic prophylaxis prescribing differs by dental setting. Therefore, the goal of this study was to compare the prescribing of antibiotic prophylaxis in Veterans Affairs (VA) and non-Veterans Affairs settings. METHODS: This was a retrospective study of veteran and non-veteran dental patients with cardiac conditions or prosthetic joints between 2015-2017. Multivariable log binomial regression analysis was conducted to compare concordant prescribing by setting with a sub-analysis for errors of dosing based on antibiotic duration (i.e., days prescribed). RESULTS: A total of 61,124 dental visits that received a prophylactic antibiotic were included. Most were male (61.0%), and 55 years of age or older (76.2%). Nearly a third (32.7%) received guideline concordant prophylaxis. VA dental settings had a lower prevalence of guideline concordant prescribing compared to non-VA settings in unadjusted results (unadjusted prevalence ratio [uPR] = 0.92, 95% CI: 0.90-0.95). After adjustment, prevalence of guideline concordant prescribing was higher in those with prosthetic joints in the VA setting (adjusted prevalence ratio [aPR] = 1.73, 95% CI: 1.59-1.88), with no difference identified in those without a prosthetic joint (aPR = 0.99, 95% CI: 0.96-1.01). Concordance of dosing was higher in VA compared to non-VA settings (aPR = 1.11, 95% CI: 1.07-1.15). CONCLUSIONS: VA has a higher prevalence of guideline concordant prescribing among those with prosthetic joints and when assessing dosing errors. Though the presence of an integrated electronic health record (EHR) may be contributing to these differences, other system or prescriber-related factors may be responsible. Future studies should focus on to what extent the integrated EHR may be responsible for increased guideline concordant prescribing in the VA setting.

Partner and Relationship Characteristics Determining Intimate Partner Violence Among Women Living with HIV in Ruili, China.

Intimate partner violence (IPV) in China is a largely understudied, major health risk among women living with HIV. Using structured face-to-face interviews, this research examined partner and couple relationship characteristics associated with physical and sexual IPV among 219 HIV-positive women living with a male partner in Ruili, China. Twenty-nine women (13%) reported past-year occurrences of physical IPV, and 24 (11%) reported sexual IPV. Physical IPV was more common when the woman's partner was of Jingpo ethnicity, drank weekly, or learned of her HIV status indirectly from a third person. Reduced risk of physical IPV was associated with a woman's perceived confidant support that was available through either her partner or a minimum of 2 non-partner confidants. Sexual IPV was more often reported among women with a partner who drank frequently or was concurrently HIV-positive, or in situations where the woman was employed and the partner was not. Sexual IPV was less likely with a partner of Dai ethnicity than Han, the major ethnicity in China. Identifying determinants of IPV vulnerability among women living with HIV may help future interventions to achieve greater impact in similar settings.

Adherence to Antiretroviral Therapy Among HIV Patients in India: A Systematic Review and Meta-analysis.

We conducted a systematic review and meta-analysis to estimate the prevalence of adherence to antiretroviral therapy (ART) in India, the third largest HIV epidemic in the world. We identified peer reviewed literature published between 2007 and 2017 to extract data on ART adherence. We estimated pooled prevalence of adherence to ART using a random-effects model. Thirty-two eligible studies (n = 11,543) were included in the meta-analysis. Studies were mostly clustered in the southern and western Indian states. Overall, 77% (95% Confidence Interval 73-82; I2 = 96.80%) of patients had optimum adherence to ART. Women had higher prevalence of optimum adherence compared to men. Depression or anxiety were significant risk factors in seven of the fifteen studies reporting determinants of nonadherence. Studies should be performed to explore the reasons for gender gap in ART adherence and HIV program in India should prioritize mental health issues among HIV patients to improve ART adherence.

Virological Non-suppression and Its Correlates Among Adolescents and Young People Living with HIV in Southern Malawi.

We examined virological non-suppression (VLN) among youth ages 13-24 years receiving HIV treatment in public health facilities in six southern Malawi districts. We also tested three ART adherence measures to determine how well each identified VLN: pill counts, a Likert scale item, and a visual analogue scale. VLN was defined as HIV RNA > 1000 copies/ml. Of the 209 youth, 81 (39%) were virally non-suppressed. Male gender and stigma were independently associated with VLN; social support and self-efficacy were independently protective. Pill count had the highest positive predictive value (66.3%). Using a pill count cut-off of < 80% nonadherence, 36 (17%) of the youth were non-adherent. Of the adherent, 120 (69%) were viral suppressed. Results indicate the need to address HIV-related stigma and to bolster social support and selfefficacy in order to enhance viral suppression. In the absence of viral load testing, pill count appears the most accurate means to assess VLN.

Neighborhood community characteristics associated with HIV disease outcomes in a cohort of urban women living with HIV.

Recent studies have found geographic variations in immune and viral human immunodeficiency virus (HIV) disease outcomes associated with census measures of neighborhood poverty and segregation. Although readily available, such aggregate census measures are not based on health behavior models and provide limited information regarding neighborhood effect pathways. In contrast, survey-based measures can capture specific aspects of neighborhood disadvantage that may better inform community-based interventions. Therefore, the aim of this study is to assess the measurement validity of multi-dimensional survey measures of neighborhood disorder compared with census measures as predictors of HIV outcomes in a cohort of 197 low-income women in a major metropolitan area. The multi-dimensional survey measures were related to each other and to census measures of concentrated poverty and racial segregation, but not so highly correlated as to be uniform. We found notable variation between community areas in women's CD4 levels but there was no corresponding geographic variance in viral load, and relationships between community area measures and viral load disappeared after adjustment for individual characteristics, including HIV treatment adherence. In multilevel models adjusting for individual characteristics including substance use, depression, and HIV treatment adherence, one survey measure of neighborhood disadvantage (poor-quality built environment) and one census measure (racial segregation) were significantly associated with greater likelihood of CD4 < 500 (p < .05).

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.

Guideline concordance and antibiotic-associated adverse events between Veterans administration and non-Veterans administration dental settings: a retrospective cohort study.

Background: Antibiotics prescribed as infection prophylaxis prior to dental procedures have the potential for serious adverse drug events (ADEs). However, the extent to which guideline concordance and different dental settings are associated with ADEs from antibiotic prophylaxis is unknown. Aim: The purpose was to assess guideline concordance and antibiotic-associated ADEs and whether it differs by VA and non-VA settings. Methods: Retrospective cohort study of antibiotic prophylaxis prescribed to adults with cardiac conditions or prosthetic joints from 2015 to 2017. Multivariable logistic regression models were fit to assess the impact of ADEs, guideline concordance and dental setting. An interaction term of concordance and dental setting evaluated whether the relationship between ADEs and concordance differed by setting. Results: From 2015 to 2017, 61,124 patients with antibiotic prophylaxis were identified with 62 (0.1%) having an ADE. Of those with guideline concordance, 18 (0.09%) had an ADE while 44 (0.1%) of those with a discordant antibiotic had an ADE (unadjusted OR: 0.84, 95% CI: 0.49-1.45). Adjusted analyses showed that guideline concordance was not associated with ADEs (OR: 0.78, 95% CI: 0.25-2.46), and this relationship did not differ by dental setting (Wald χ^2 p-value for interaction = 0.601). Conclusion: Antibiotic-associated ADEs did not differ by setting or guideline concordance.

Symptom severity in an outbreak of SARS-CoV-2 at a university student gala in the Omicron era, Chicago, Illinois, April 2022.

Objective: In April 2022, the University of Illinois Chicago (UIC) COVID-19 Contact Tracing & Epidemiology Program identified an outbreak associated with an indoor student gala. This study's aims were to characterize COVID-19 transmission dynamics and measure symptom severity among cases.Participants: The study population included UIC-affiliated gala attendees. Outbreak-associated cases tested positive for COVID-19 between April 2 and April 11, 2022. Attendees who did not test positive or develop symptoms within ten days of the event were classified as contacts.Methods: We ascertained cases through phone-based contact tracing and a survey and evaluated symptom severity using a novel classification system.Results: Among 307 UIC students registered to attend the gala, the minimum attack rate was 14.0%. Approximately 56% of cases were mildly symptomatic, and 38.9% reported severe symptoms.Conclusions: Our findings align with prior research documenting heightened transmissibility of Omicron-variant-related strains and highlight the need for nuanced symptom assessment methodologies.

Implementation and effectiveness of a COVID-19 case investigation and contact tracing program at a large, urban midwestern university.

BACKGROUND: The University of Illinois Chicago (UIC) COVID-19 Contact Tracing and Epidemiology Program was critical to the university's COVID-19 incident response during the 2020-2021 academic year. We are a team of epidemiologists and student contact tracers who perform COVID-19 contact tracing among campus members. Literature is sparse on models for mobilizing non-clinical students as contact tracers; therefore, we aim to disseminate strategies that are adaptable by other institutions. METHODS: We described essential aspects of our program including surveillance testing, staffing and training models, interdepartmental partnerships, and workflows. Additionally, we analyzed the epidemiology of COVID-19 at UIC and measures of contact tracing effectiveness. RESULTS: The program was responsible for promptly quarantining 120 cases prior to converting and potentially infecting others, thereby preventing at least 132 downstream exposures and 22 COVID-19 infections from occurring. DISCUSSION: Features central to program success included routine data translation and dissemination and utilizing students as indigenous campus contact tracers. Major operational challenges included high staff turnover and adjusting to rapidly evolving public health guidance. CONCLUSIONS: Institutes of higher education provide fertile ground for effective contact tracing, particularly when comprehensive networks of partners facilitate compliance with institution-specific public health requirements.

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.

Prevalence of drug resistant tuberculosis among patients at high-risk for Hiv attending outpatient clinics in Delhi, India.

We sought to determine tuberculosis (TB) prevalence including multidrug resistant (MDR)-TB among a cohort of high risk patients at two directly observed treatment short course (DOTS) clinics in Delhi, India. We also aimed to compare the sensitivity of acid-fast bacilli (AFB) smear tests for patients with HIV using sputum cultures as the gold standard. A cross-section study was conducted among adult patients (> or = 18 years old) with prolonged cough (greater than two weeks), night sweats, fever, and/or weight loss suspected of pulmonary TB between February and March 2006. Sputum samples were obtained and processed for 165 patients; 53 (32.1%) were culture positive for TB. Patients with TB were predominantly male (92.1%), young (median age of 32 years), and the HIV-seroprevalence was high (41.5%). In the multivariable analysis adjusted for age, HIV infection was significantly associated (POR = 2.0, p < 0.05) with the presence of TB disease. Among Mycobacterium tuberculosis isolates recovered from 53 cases, 25 (47.2%) were resistant to > or = 1 first line anti-TB drugs and 7 (13.2%) were MDR-TB. The sensitivity of AFB smears among HIV negative and positive participants was 35.5% and 18.0%, respectively. Our findings demonstrated that the sensitivity of AFB smears to detect TB among HIV positive patients was low. Additionally, we found that even in regions where population drug resistance estimates are low, sentinel surveillance of MDR-TB in high-risk populations is useful to prioritize target groups in need of additional prevention, monitoring and health outreach.

Head and neck squamous cell carcinomas among males of the three largest Asian diasporas in the US, 2004-2013.

BACKGROUND: Head and neck squamous cell carcinomas (HNSCC) have not been fully examined in the Asian diasporas in the US, despite certain Asian countries having the highest incidence of specific HNSCCs. METHODS: National Cancer Database was used to compare 1046 Chinese, 887 South Asian (Indian/Pakistani), and 499 Filipino males to 156,927 Non-Hispanic White (NHW) males diagnosed with HNSCC between 2004-2013. Multinomial logistic regression was used to assess the association of race/ethnicity with two outcomes - site group and late-stage diagnosis. Temporal trends were explored for site groups and subsites. RESULTS: South Asians had a greater proportion of oral cavity cancer [OCC] compared to NHWs (59 % vs. 25 %; ORadj =7.3 (95 % CI: 5.9-9.0)). In contrast, Chinese (64 % vs. 9%; ORadj =34.0 (95 % CI: 26.5-43.6)) and Filipinos (47 % vs. 9%; ORadj =10.0 (95 % CI: 7.8-12.9)) had a greater proportion of non-oropharyngeal cancer compared to NHWs. All three Asian subgroups had a higher likelihood of being diagnosed by age 40 (14 % Chinese, 10 % South Asian and 8% Filipino compared to 3% in NHW; p < 0.001). Chinese males had lower odds of late-stage diagnosis, compared to NHWs. South Asian cases doubled from 2004 to 2013 largely due to an increase in OCC cases (34 cases in 2004 to 86 in 2013). CONCLUSION: Asian diasporas are at a higher likelihood of specific HNSCCs. Risk factors, screening and survival need to be studied further, and policy changes are needed to promote screening and to discourage high-risk habits in these Asian subgroups.

Characteristics Associated With Opioid and Antibiotic Prescribing by Dentists.

INTRODUCTION: The objective of this study is to identify county-level characteristics that may be high-impact targets for opioid and antibiotic interventions to improve dental prescribing. METHODS: Prescriptions during 2012-2017 were extracted from the IQVIA Longitudinal Prescription database. Primary outcomes were yearly county-level antibiotic and opioid prescribing rates. Multivariable negative binomial regression identified associations between prescribing rates and county-level characteristics. All analyses occurred in 2020. RESULTS: Over time, dental opioid prescribing rates decreased by 20% (from 4.02 to 3.22 per 100 people), whereas antibiotic rates increased by 5% (from 6.85 to 7.19 per 100 people). Higher number of dentists per capita, higher proportion of female residents, and higher proportion of residents aged <65 years were associated with increased opioid rates. Relative to location in the West, location in the Northeast (59%, 95% CI=52, 65) and Midwest (64%, 95% CI=60, 70) was associated with lower opioid prescribing rates. Higher clinician density, median household income, proportion female, and proportion White were all independently associated with higher antibiotic rates. Location in the Northeast (149%, 95% CI=137, 162) and Midwest (118%, 95% CI=111, 125) was associated with higher antibiotic rates. Opioid and antibiotic prescribing rates were positively associated. CONCLUSIONS: Dental prescribing of opioids is decreasing, whereas dental antibiotic prescribing is increasing. High prescribing of antibiotics is associated with high prescribing of opioids. Strategies focused on optimizing dental antibiotics and opioids are needed given their impact on population health.

Antiretroviral therapy adherence among treatment-naive HIV-infected patients.

OBJECTIVE: To determine the incidence of antiretroviral therapy (ART) adherence among treatment-naive HIV-infected patients and to evaluate the impact of single-tablet regimen (STR) on ART adherence among this population. DESIGN: Retrospective cohort study. METHODS: We used a nationally representative sample of IQVIA LRx Lifelink individual level pharmacy claims database during 2011-2016, and defined adult patients with index date (first complete ART regimen prescription fill date) after 30 June 2011 as treatment naïve. We estimated ART adherence, measured as the proportion of days covered during 1 year following the index date. We conducted multivariable analysis to identify the factors associated with optimum adherence (≥90% proportion of days covered). We also compared adherence between patients prescribed STR and multiple-tablet regimens among those prescribed integrase strand transfer inhibitor-based or nonnucleoside reverse transcriptase inhibitor-based regimens. RESULTS: Overall 42.9% of the patients were optimally adherent. Adherence was significantly lower among blacks, Hispanics and patients in low-income communities. Adjusting for the covariates, patients on STR had higher incidence of optimum adherence compared with those on multiple-tablet regimens among patients on integrase strand transfer inhibitor-based regimens [49 vs. 24%, relative risk, 2.16 (95% confidence interval: 1.96-2.26)], but no significant difference was observed among those on nonnucleoside reverse transcriptase inhibitor-based regimen [45 vs. 45%, relative risk, 1.12 (95% confidence interval: 0.99-1.26)]. CONCLUSION: Low ART adherence observed among treatment-naive patients in this nationally representative study suggests the need for public health interventions to improve adherence among this population.

Effects of vitamin K1 treatment on plasma concentrations of long-acting anticoagulant rodenticide enantiomers following inhalation of contaminated synthetic cannabinoids.

Background: An outbreak of synthetic cannabinoid (SC)-associated coagulopathy and bleeding in Illinois, USA was determined to be due to inhalation of SC contaminated with brodifacoum (BDF), difenacoum (DiF), and bromadiolone (BDL), highly potent long-acting anticoagulant rodenticides (LAARs). Treatment with high-dose vitamin K1 (VK1) prevented mortality; however, plasma LAAR levels were not measured risking recurrence of coagulopathy and bleeding due to premature discontinuation. The goal of this study was to determine if plasma LAAR levels were reduced following standard of care treatment to normalize coagulopathy.Methods: Blood samples were collected from a cohort of 32 patients, and ultra-high performance liquid chromatography-tandem mass spectrometry (UHPLC-MS/MS) analysis used to quantify plasma LAAR levels including enantiomers.Results: BDF was detected in 31 samples; 30 also contained DiF and 18 contained BDL. Initial plasma levels were 581 ± 87, 11.0 ± 1.9, and 14.9 ± 5.9 ng/mL for BDF, DiF, and BDL, respectively (mean ± SE). At discharge plasma, BDF levels remained elevated at 453 ± 68 ng/mL. Plasma half-lives for BDF, DiF, and BDL were 7.5 ± 1.3, 7.2 ± 1.9, and 1.8 ± 0.3 days, respectively. The half-life for trans-BDF enantiomers (5.7 ± 0.8 days) was shorter than for cis-enantiomers (7.6 ± 1.9 days). BDF half-lives were shorter, and coagulopathy normalized faster in patients receiving intravenous VK1 as compared to oral VK1. Patients prescribed VK1 at discharge had fewer re-admittances.Conclusions: These results demonstrate that plasma LAAR levels at discharge were elevated in poisoned patients despite normal coagulation, and that the route of VK1 administration affected LAAR pharmacokinetics and INR normalization. We propose plasma LAAR levels and coagulation be monitored concomitantly during follow-up of patients with LAAR poisoning. KEY POINTSIn patients treated with high-dose vitamin K1 for LAAR poisoning, plasma levels remained 40-fold above safe levels upon discharge from hospital.LAAR half-lives, normalization of coagulopathy, and readmittances were reduced by treatment with intravenous vitamin K1.

Lessons learned from Chicago's emergency response to mass evacuations caused by Hurricane Katrina.

OBJECTIVES: We analyzed the response of the Chicago Department of Public Health with respect to its effectiveness in providing health care to Hurricane Katrina evacuees arriving in the city. METHODS: Between September 12 and October 21, 2005, we conducted a real-time qualitative assessment of a medical unit in Chicago's Hurricane Victim Welcome and Relief Center. A semistructured guide was used to interview 33 emergency responders in an effort to identify key operational successes and failures. RESULTS: The medical unit functioned at a relatively high level, primarily as a result of the flexibility, creativity, and dedication of its staff and the presence of strong leadership. Chronic health care services and prescription refills were the most commonly mentioned services provided, and collaboration with a national pharmacy proved instrumental in reconstructing medication histories. The lack of a comprehensive and well-communicated emergency response plan resulted in several preventable inefficiencies. CONCLUSIONS: Our findings highlight the need for improved planning for care of evacuee populations after a major emergency event and the importance of ensuring continuity of care for the most vulnerable. We provide an emergency response preparedness checklist for local public health departments.

Predictors and outcomes of antibiotic adequacy for bloodstream infections in veterans with spinal cord injury.

OBJECTIVE: To identify predictors and outcomes associated with receiving inadequate empirical antimicrobial treatment for bloodstream infections (BSIs) in persons with spinal cord injury (SCI). DESIGN: Retrospective cohort study from October 1, 1997, through September 30, 2004. SETTING: A Department of Veterans Affairs SCI center that serves approximately 700 patients a year. PARTICIPANTS: Hospitalized patients with SCI (N=123) who had 1 or more BSIs during the study period. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Adequacy of antimicrobial treatment (inadequate treatment was defined as the absence of antimicrobial agents for a particular organism within 2 days after the collection of blood cultures and/or the microorganism's resistance to the antimicrobial administered), hospital length of stay (LOS) post-BSI infection, and in-hospital and 30-day mortality. Cluster-adjusted multivariable models were assessed. RESULTS: Over one third (88; 37.4%) of the 235 episodes of BSI identified received inadequate empirical antibiotic treatment. Having a polymicrobial BSI was associated with inadequate treatment (odds ratio [OR]=3.28; 95% confidence interval [CI]=1.62-6.65; P=.001). Factors protective against inadequate therapy included having a comorbid pressure ulcer (OR=0.37; 95% CI=0.21-0.68; P=.001) or a BSI that was not primary (OR=0.30; 95% CI=0.15-0.58; P<.0001). Mortality did not differ between the inadequate and adequate treatment groups (11.4% vs 10.9%; P=.92). Similarly LOS postinfection was not affected by treatment status (inadequate treatment median=22d vs adequate treatment median=27d; P=.98). CONCLUSIONS: Over one third of patients received inadequate empirical treatment, which was associated with having a polymicrobial BSI. However, inadequate treatment was not associated with increased mortality or LOS postinfection.

Should Cytochrome P450 Inducers be Used to Accelerate Clearance of Brodifacoum from Poisoned Patients?

A recent multi-state outbreak of life-threatening bleeding following inhalation of synthetic cannabinoids has been attributed to contamination with the long-acting anticoagulant rodenticide (LAAR) brodifacoum, a second-generation, highly potent, long-acting derivative of the commonly used blood thinner warfarin. While long-term treatment with high-dose vitamin K1 restores coagulation, it does not affect brodifacoum metabolism or clearance, and, consequently, brodifacoum remains in the human body for several months, thereby predisposing to risk of bleeding recurrence and development of coagulation-independent injury in extrahepatic tissues and fetuses. This has prompted the evaluation of pharmacological measures that accelerate brodifacoum clearance from poisoned patients. Since the induction of certain cytochrome P450 (CYP) enzymes accelerates warfarin metabolism, using CYP inducers, such as phenobarbital, to accelerate brodifacoum clearance seems plausible. However, unlike warfarin, brodifacoum does not undergo significant metabolism in the liver, nor have the effects of phenobarbital on vitamin K1 metabolism been previously determined. In addition, the safety of phenobarbital in brodifacoum-poisoned patients has not been established. Therefore, we propose that CYP inducers should not be used to accelerate the clearance of brodifacoum from poisoned patients, but that alternative approaches such as reducing enterohepatic recirculation of brodifacoum, or using lipid emulsions to scavenge brodifacoum throughout the body, be considered.

Assessment of the Appropriateness of Antibiotic Prescriptions for Infection Prophylaxis Before Dental Procedures, 2011 to 2015.

Importance: Antibiotics are recommended before certain dental procedures in patients with select comorbidities to prevent serious distant site infections. Objective: To assess the appropriateness of antibiotic prophylaxis before dental procedures using Truven, a national integrated health claims database. Design, Setting, and Participants: Retrospective cohort study. Dental visits from 2011 to 2015 were linked to medical and prescription claims from 2009 to 2015. The dates of analysis were August 2018 to January 2019. Participants were US patients with commercial dental insurance without a hospitalization or extraoral infection 14 days before antibiotic prophylaxis (defined as a prescription with ≤2 days' supply dispensed within 7 days before a dental visit). Exposures: Presence or absence of cardiac diagnoses and dental procedures that manipulated the gingiva or tooth periapex. Main Outcomes and Measures: Appropriate antibiotic prophylaxis was defined as a prescription dispensed before a dental visit with a procedure that manipulated the gingiva or tooth periapex in patients with an appropriate cardiac diagnosis. To assess associations between patient or dental visit characteristics and appropriate antibiotic prophylaxis, multivariable logistic regression was used. A priori hypothesis tests were performed with an α level of .05. Results: From 2011 to 2015, antibiotic prophylaxis was prescribed for 168 420 dental visits for 91 438 patients (median age, 63 years; interquartile range, 55-72 years; 57.2% female). Overall, these 168 420 dental visits were associated with 287 029 dental procedure codes (range, 1-14 per visit). Most dental visits were classified as diagnostic (70.2%) and/or preventive (58.8%). In 90.7% of dental visits, a procedure was performed that would necessitate antibiotic prophylaxis in high-risk cardiac patients. Prevalent comorbidities include prosthetic joint devices (42.5%) and cardiac conditions at the highest risk of adverse outcome from infective endocarditis (20.9%). Per guidelines, 80.9% of antibiotic prophylaxis prescriptions before dental visits were unnecessary. Clindamycin was more likely to be unnecessary relative to amoxicillin (odds ratio [OR], 1.10; 95% CI, 1.05-1.15). Prosthetic joint devices (OR, 2.31; 95% CI, 2.22-2.41), tooth implant procedures (OR, 1.66; 95% CI, 1.45-1.89), female sex (OR, 1.21; 95% CI, 1.17-1.25), and visits occurring in the western United States (OR, 1.15; 95% CI, 1.06-1.25) were associated with unnecessary antibiotic prophylaxis. Conclusion and Relevance: More than 80% of antibiotics prescribed for infection prophylaxis before dental visits were unnecessary. Implementation of antimicrobial stewardship in dental practices is an opportunity to improve antibiotic prescribing for infection prophylaxis.