Identification of risk factors for failure in patients with skin and soft tissue infections.

PURPOSE: The purpose was to determine significant predictors of treatment failure of skin and soft tissue infections (SSTI) in the inpatient and outpatient setting. METHODS: A retrospective chart review of patients treated between January 1, 2005 to July 1, 2016 with ICD-9 or ICD-10 code of cellulitis or abscess. The primary outcome was failure defined as an additional prescription or subsequent hospital admission within 30 days of treatment. Risk factors for failure were identified through multivariate logistic regression. RESULTS: A total of 541 patients were included. Seventeen percent failed treatment. In the outpatient group, 24% failed treatment compared to 9% for inpatients. Overweight/obesity (body mass index (BMI) > 25 kg/m2) was identified in 80%, with 15% having a BMI >40 kg/m2. BMI, heart failure, and outpatient treatment were determined to be significant predictors of failure. The unit odds ratio for failure with BMI was 1.04 (95% [Cl] = 1.01 to 1.1, p = 0.0042). Heart failure increased odds by 2.48 (95% [Cl] = 1.3 to 4.7, p = 0.0056). Outpatients were more likely to fail with an odds ratio of 3.36. CONCLUSION: Patients with an elevated BMI and heart failure were found to have increased odds of failure with treatment for SSTIs. However, inpatients had considerably less risk of failure than outpatients. These risk factors are important to note when making the decision whether to admit a patient who presents with SSTI in the emergency department. Thoughtful strategies are needed with this at-risk population to prevent subsequent admission.

Proper Antibiotic Use in a Home-Based Primary Care Population Treated for Urinary Tract Infections.

OBJECTIVE: To evaluate the trends associated with diagnosis and treatment of urinary tract infections (UTI) in a home-based primary care population of Veterans Health System patients from 2006 to 2015. DESIGN: Retrospective cohort study. SETTING: Veterans Healthcare System. PARTICIPANTS: Home-based primary care patients treated for UTI from 2006 to 2015. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Appropriate therapy was determined based on the McGeer criteria. Multivariate logistic regression was used to determine factors leading to appropriate UTI treatment. RESULTS: Of 366 available patients, 68 (18.6%) were tested for a UTI. Appropriate therapy occurred in 26% of patients. Allergy to any antibiotic increased the odds of appropriate treatment (odds ratio [OR] = 5.6, 95% confidence interval [CI] 1.5-23.2). Flank pain and increased urinary frequency also increased the likelihood of being treated appropriately (OR = 25.9, 95% CI 2.9-584.0 and OR = 4.49, 95% CI 0.99-21.2, respectively). CONCLUSION: Antibiotics were overused for treating UTIs in the homebound population. Patients with flank pain, increased urinary frequency, and antibiotic allergy were more likely to receive appropriate treatment. Pharmacists, therefore, have a viable opportunity to increase appropriate antibiotic prescribing in the home-based primary care population.

Obesity and Heart Failure as Predictors of Failure in Outpatient Skin and Soft Tissue Infections.

The purpose of this study was to evaluate risk factors for failure of antibiotic treatment within 30 days for uncomplicated skin infections of outpatients treated in a Veterans Affairs hospital. A retrospective chart review of outpatients between January 2006 and July 2015 with an ICD-9 (International Statistical Classification of Diseases and Related Health Problems) code of cellulitis or abscess was included in the analysis. The primary outcome was success versus failure of the antibiotic, with failure defined as another antibiotic prescribed or hospitalization within 30 days for the original indication. A total of 293 patients were included in the final analysis, 24% of whom failed within 30 days. Obesity/overweight (body mass index [BMI] of >25 kg/m2) was identified in 83% of the overall population, with 16% of that population having a BMI greater than 40 kg/m2 An elevated mean BMI of 34.2 kg/m2 (P = 0.0098) was found in the subset of patients who failed oral antibiotics compared to a BMI of 31.32 kg/m2 in patients who were treated successfully. Additionally, the patients who failed had an increased prevalence of heart failure at 16% (P = 0.027). Using multivariate logistic regression, BMI and heart failure were determined to be significant predictors of antibiotic prescription failure. Each 10-kg/m2 unit increase in BMI was associated with a 1.62-fold-greater odds of failure. A diagnosis of heart failure increased the odds of failure by 2.6-fold (range, 1.1- to 5.8-fold). Outpatients with uncomplicated skin infections with an elevated BMI and heart failure were found to have increased odds of failure, defined as hospitalization or additional antibiotics within 30 days.

Impact of Penicillin Allergy on Time to First Dose of Antimicrobial Therapy and Clinical Outcomes.

PURPOSE: The objective of this study was to evaluate the impact of a listed penicillin allergy on the time to first dose of antibiotic in a Veterans Affairs hospital. Additional clinical outcomes of patients with penicillin allergies were compared with those of patients without a penicillin allergy. METHODS: A retrospective chart review of veterans admitted through the emergency department with a diagnosis of pneumonia, urinary tract infection, bacteremia, and sepsis from January 2006 to December 2015 was conducted. The primary outcome was time to first dose of antibiotic treatment, defined as the time from when the patient presented to the emergency department to the medication administration time. Secondary outcomes included total antibiotic therapy duration and treatment outcomes, including mortality, length of stay, and 30-day readmission rate. FINDINGS: A total of 403 patients were included in the final analysis; 57 patients (14.1%) had a listed penicillin allergy. The average age of the population was 75 years and 99% of the population was male. The mean time to first dose of antibiotic treatment for patients with a penicillin allergy was prolonged compared with those without a penicillin allergy (236.1 vs 186.6 minutes; P = 0.03), resulting in an approximately 50-minute delay. Penicillin-allergic patients were more likely to receive a carbapenem or fluoroquinolone antibiotic (P < 0.0001). IMPLICATIONS: Patients with a penicillin allergy had a prolonged time to first dose of antibiotic therapy. No significant differences were found in total antibiotic duration, length of stay, or 30-day readmission rate. The small sample size, older population, and single-center nature of this study may limit the generalizability of the present findings to other populations.

Decreased mortality in patients prescribed vancomycin after implementation of antimicrobial stewardship program.

BACKGROUND: The impact of an antimicrobial stewardship program (ASP) on 30-day mortality rates was evaluated in patients prescribed vancomycin in a Veterans Affairs hospital. METHODS: A retrospective chart review of patients receiving a minimum of 48 hours of vancomycin during October 2006-July 2014. A multivariate logistic regression analysis was used to determine predictors of mortality. Interventions of the ASP consist of appropriate antibiotic selection, dosing, microbiology, and treatment duration. RESULTS: Death occurred in 12.4% of 453 patients. Of the 56 deaths, 64.3% occurred during prestewardship versus 35.7% during stewardship (P = .021). Increased mortality was associated with pre-ASP (odds ratio [OR], 2.17; 95% confidence interval [CI], 1.13-4.27), age (unit OR, 1.08; 95% CI, 1.05-1.12), nephrotoxicity (OR, 3.24; 95% CI, 1.27-8.01), and hypotension (OR, 3.28; 95% CI, 1.42-7.44). Patients treated in the intensive care unit were associated with increased mortality. Patients in the stewardship group experienced lower rates of mortality, which may be caused by interventions initiated by the stewardship team, including minimizing nephrotoxicity and individualized chart review. CONCLUSIONS: Mortality in patients treated with vancomycin was decreased after antimicrobial stewardship was implemented. As anticipated, older age, hypotension, nephrotoxicity, and intensive care unit admission were associated with an increased incidence of mortality.

Review of Safety and Efficacy of Sleep Medicines in Older Adults.

PURPOSE: Insomnia is problematic for older adults. After behavioral modifications fail to show adequate response, pharmacologic options are used. The pharmacokinetics of agents used to treat insomnia may be altered. This review focuses on the safety and efficacy of medications used to treat insomnia. METHODS: A literature search of Medline, PubMed, and Embase was conducted (January 1966-June 2016). It included systematic reviews, randomized controlled trials, observational studies, and case series that had an emphasis on insomnia in an older population. Search terms included medications approved by the US Food and Drug Administration for insomnia: benzodiazepines (triazolam, estazolam, temazepam, flurazepam, and quazepam), nonbenzodiazepine receptor agonists (non-BzRAs; zaleplon, zolpidem, and eszopiclone), suvorexant, ramelteon, doxepin and trazodone. Off-label drugs such as other antidepressants, antihistamines, antipsychotics, gabapentin, pramipexole, tiagabine, valerian, and melatonin were also included. FINDINGS: Cognitive behavioral therapy and sleep hygiene are considered initial therapy for insomnia. Benzodiazepines are discouraged in the geriatric population, especially for long-term use. Although non-BzRAs have improved safety profiles compared with benzodiazepines, their side effects include dementia, serious injury, and fractures, which should limit their use. Ramelteon has a minimal adverse effect profile and is effective for sleep-onset latency and increased total sleep time, making it a valuable first-line option. Although the data on suvorexant are limited, this drug improves sleep maintenance and has mild adverse effects, including somnolence; residual daytime sedation has been reported, however. Sedating low-dose antidepressants should only be used for insomnia when the patient has comorbid depression. Antipsychotic agents, pramipexole, and tiagabine have all been used for insomnia, but none has been extensively studied in an older population, and all have considerable adverse effects. Gabapentin may be useful in patients with restless leg syndrome or chronic neuropathic pain and insomnia. Diphenhydramine should be avoided in the elderly. Valerian and melatonin are unregulated products that have a small impact on sleep latency and can produce residual sedation. IMPLICATIONS: An ideal treatment for insomnia should help to improve sleep latency and sleep duration with limited awakenings and be without significant adverse effects such as daytime somnolence or decreased alertness. Cognitive behavioral therapy should always be first line treatment. Clinical inertia regarding previous prominent use of benzodiazepines and non-BzRAs will be a significant challenge for patients accustomed to their issuance. The future direction of insomnia treatment should have an emphasis on nonpharmacologic interventions, treating comorbid conditions, and focusing therapy on using benzodiazepines and non-BzRAs as last resorts.