Estimated Cardiac Risk Associated With Macrolides and Fluoroquinolones Decreases Substantially When Adjusting for Patient Characteristics and Comorbidities.

BACKGROUND: Some studies have found that antimicrobials, especially macrolides, increase the risk of cardiovascular death. We investigated potential cardiac-related events associated with antimicrobial use in a population of patients with acute myocardial infarction. METHODS AND RESULTS: For 185 010 Medicare beneficiaries, we recorded prescriptions for azithromycin, clarithromycin, levofloxacin, moxifloxacin, doxycycline, and amoxicillin-clavulanate. In the following week, we recorded death, acute myocardial infarction, atrial fibrillation or atrial flutter, a non-atrial fibrillation/atrial flutter arrhythmia, or ventricular arrhythmia. We fit unadjusted and adjusted logistic regression models using generalized estimating equations. Adjusted models included patients' comorbidities, medications, procedures, demographics, insurance status, time since index acute myocardial infarction, number of visits, and the influenza rate. In unadjusted analyses, macrolides and fluoroquinolones were associated with a risk of cardiac events. However, the risk associated with macrolide use was substantially attenuated after adjustment for a wide range of variables, and the risk associated with fluoroquinolones was no longer statistically significant. For example, for azithromycin, the odds ratio for any cardiac event or death was 1.35 (95% confidence interval, 1.27-1.44; P<0.0001), but after controlling for a wide range of covariates, the odds ratio decreased to 1.01 (95% confidence interval, 0.95-1.08; P<0.6688). CONCLUSIONS: Controlling for covariates explains much of the adverse cardiac risk associated with antimicrobial use found in other studies. Most antimicrobials are not associated with risk of cardiac events, and others, specifically azithromycin and clarithromycin, may pose a small risk of certain cardiac events. However, the modest potential risks attributable to these antimicrobials must be weighed against the drugs' considerable and immediate benefits.

Phantom Prescribing: Examining the Frequency of Antimicrobial Prescriptions Without a Patient Visit.

OBJECTIVE To investigate the scale of antimicrobial prescribing without a corresponding visit, and to compare the attributes of patients who received antimicrobials with a corresponding visit with those who did not have a visit. DESIGN Retrospective cohort. METHODS We followed up 185,010 Medicare patients for 1 year after an acute myocardial infarction. For each antimicrobial prescribed, we determined whether the patient had an inpatient, outpatient, or provider claim in the 7 days prior to the antimicrobial prescription being filled. We compared the proportions of patient characteristics for those prescriptions associated with a visit and without a visit (ie, phantom prescriptions). We also compared the rates at which different antimicrobials were prescribed without a visit. RESULTS We found that of 356,545 antimicrobial prescriptions, 14.75% had no evidence of a visit in the week prior to the prescription being filled. A higher percentage of patients without a visit were identified as white (P<.001) and female (P<.001). Patients without a visit had a higher likelihood of survival and fewer additional cardiac events (acute myocardial infarction, cardiac arrest, stroke, all P<.001). Among the antimicrobials considered, amoxicillin, penicillin, and agents containing trimethoprim and methenamine were much more likely to be prescribed without a visit. In contrast, levofloxacin, metronidazole, moxifloxacin, vancomycin, and cefdinir were much less likely to be prescribed without a visit. CONCLUSIONS Among this cohort of patients with chronic conditions, phantom prescriptions of antimicrobials are relatively common and occurred more frequently among those patients who were relatively healthy. Infect Control Hosp Epidemiol 2017;38:273-280.

Youth Football Injuries: A Prospective Cohort.

BACKGROUND: There are approximately 2.8 million youth football players between the ages of 7 and 14 years in the United States. Rates of injury in this population are poorly described. Recent studies have reported injury rates between 2.3% and 30.4% per season and between 8.5 and 43 per 1000 exposures. HYPOTHESIS: Youth flag football has a lower injury rate than youth tackle football. The concussion rates in flag football are lower than in tackle football. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: Three large youth (grades 2-7) football leagues with a total of 3794 players were enrolled. Research personnel partnered with the leagues to provide electronic attendance and injury reporting systems. Researchers had access to deidentified player data and injury information. Injury rates for both the tackle and flag leagues were calculated and compared using Poisson regression with a log link. The probability an injury was severe and an injury resulted in a concussion were modeled using logistic regression. For these 2 responses, best subset model selection was performed, and the model with the minimum Akaike information criterion value was chosen as best. Kaplan-Meier curves were examined to compare time loss due to injury for various subgroups of the population. Finally, time loss was modeled using Cox proportional hazards regression models. RESULTS: A total of 46,416 exposures and 128 injuries were reported. The mean age at injury was 10.64 years. The hazard ratio for tackle football (compared with flag football) was 0.45 (95% CI, 0.25-0.80; P = .0065). The rate of severe injuries per exposure for tackle football was 1.1 (95% CI, 0.33-3.4; P = .93) times that of the flag league. The rate for concussions in tackle football per exposure was 0.51 (95% CI, 0.16-1.7; P = .27) times that of the flag league. CONCLUSION: Injury is more likely to occur in youth flag football than in youth tackle football. Severe injuries and concussions were not significantly different between leagues. Concussion was more likely to occur during games than during practice. Players in the sixth or seventh grade were more likely to suffer a concussion than were younger players.