How to 'SAVE' antibiotics: effectiveness and sustainability of a new model of antibiotic stewardship intervention in the internal medicine area.

BACKGROUND: Antibiotic stewardship (AS) is a cornerstone of the fight against antimicrobial resistance; however, evidence on the best practice to improve antibiotic prescription in various hospital settings is still scarce. This study aimed to measure the efficacy of a non-restrictive AS intervention in the internal medicine area of a tertiary-care hospital across a 3-year period. METHODS: The intervention comprised a 3-month 'intensive phase' based on education and guidelines provision, followed by 9 months of audits and feedback activities. The primary outcome was the overall antibiotic consumption measured as days of therapy (DOTs) and defined daily doses (DDDs). Secondary outcomes were carbapenem and fluoroquinolone consumption, all-cause in-hospital mortality, length of stay, incidence of Clostridioides difficile and carbapenem-resistant Enterobacterales bloodstream infections (CRE-BSIs). All outcomes were measured in the intervention wards comparing the pre-phase with the post-phase using an interrupted time-series model. RESULTS: A total of 145 337 patient days (PDs) and 14 159 admissions were included in the analysis. The intervention was associated with reduced DOTs*1000PDs (-162.2/P = 0.005) and DDDs*1000PDs (-183.6/P ≤ 0.001). A sustained decrease in ward-related antibiotic consumption was also detected during the post-intervention phase and in the carbapenem/fluoroquinolone classes. The intervention was associated with an immediate reduction in length of stay (-1.72 days/P < 0.001) and all-cause mortality (-3.71 deaths*100 admissions/P = 0.002), with a decreasing trend over time. Rates of Clostridioides difficile infections and CRE-BSIs were not significantly impacted by the intervention. CONCLUSIONS: The AS intervention was effective and safe in decreasing antibiotic consumption and length of stay in the internal medicine area. Enabling prescribers to judicious use of antimicrobials through active participation in AS initiatives is key to reach sustained results over time.

The Importance of Nutrition in Hypertension.

Arterial hypertension (AH) is considered to be one of the most relevant cardiovascular risk factors, and its wide prevalence in all age ranges makes it necessary to analyse all the possible causes and treatments. In this special issue, nutritional interventions are examined either as causes or as treatments of AH. [...].

Longitudinal body composition changes in old men and women: interrelationships with worsening disability.

BACKGROUND: Few studies have evaluated prospectively age-related body composition changes and their relationships with worsening disability in the elderly population. METHODS: Ninety-seven women and 62 men aged 71.4+/-2.2 and 71.6+/-2.2 years, respectively, at baseline underwent dual-energy x-ray absorptiometry determinations at baseline and at 2- and 5.5-year follow-up intervals to measure total body and leg fat (FM) and total, appendicular, and leg fat-free mass (FFM). Height, weight, body mass index (BMI), and waist circumference (as well as reported disabilities using a four-level scale) were evaluated at baseline and at 2- and 5.5-year follow-up. RESULTS: In both sexes, total FM did not change significantly, while total, appendicular, and leg FFM significantly decreased over the study follow-up. In men and women losing weight, BMI, total and leg FM, and total, appendicular, and leg FFM significantly decreased. In weight-stable men and women, appendicular and leg FFM significantly decreased and BMI, waist circumference, and total FM significantly increased. Men lost significantly more total, appendicular, and leg FFM than did women, irrespective of whether they maintained or lost weight. Over the follow-up period, 43.3% of women and 43.5% of men declined in one or more levels of reported disability. We evaluated the effect of age, baseline BMI, FM, FFM, number of diseases, baseline 6-minute walking test, categories of weight change, total, appendicular, or leg FFM changes, total FM and waist changes on the probability of a decline in one or more levels of reported disability score over the follow-up period, taking into account sex. Patients losing appendicular and leg FFM were 2.15 and 2.53 times, respectively, more likely to report increased disability than were patients without FFM loss. CONCLUSIONS: Reduction in appendicular or leg FFM was the main predictor of decline in one or more levels of reported disability in older men and women, and accounted for about a 2-fold increase in risk.

The anorexia of aging.

Malnutrition in the elderly is one of the greatest threats to health, well-being and autonomy, it is therefore crucial to understand and to contrast the causal factors of inadequate energy intake. This review focuses on the mechanisms of the so-called 'anorexia of aging'. In recent years, it has been shown that elderly subjects have abnormal peripheral signal patterns and alterations in central hypothalamic control relays. Negative feedback from impaired gastric motility, exaggerated long-term adiposity signals (leptin, insulin) and postprandial anorexigenic signals (CCK, PYY) seem to prevail over the central feeding drive. If nutritional strategies of intervention are to be improved, these data need to be taken into account.

Unbalanced serum leptin and ghrelin dynamics prolong postprandial satiety and inhibit hunger in healthy elderly: another reason for the "anorexia of aging".

BACKGROUND: In healthy elderly, a reduction from the appetite and food intake of younger years has been defined as the "anorexia of aging," which may cause malnutrition. Leptin and ghrelin may alter the control of hunger and satiety and thus lead to anorexia. OBJECTIVE: The aim of this study was to investigate how aging affects serum leptin and ghrelin concentrations in response to a meal and the relation of those hormones to hunger and satiety sensations. DESIGN: We studied 8 community-dwelling elderly (x +/- SD age: 78 +/- 1 y) subjects and 8 younger (29.5 +/- 1 y) control subjects. Under fasting conditions and for 4 h after an 800-kcal mixed meal, satiety and hunger were evaluated at intervals, by using a visual analogic scale. Blood samples for leptin, ghrelin, and insulin measurements were collected at the following times: 30 min before and immediately and 30, 60, 120, and 240 min after the meal. RESULTS: Postprandial satiety lasted significantly longer in the elderly than in the control subjects, and hunger was suppressed in the elderly throughout the observation. Fasting leptin was higher in the elderly than in the young (x +/- SE: 4.3 +/- 1.9 and 1.3 +/- 0.4 ng/mL, respectively; P < 0.05), and postprandial fluctuation was not significant. Fasting insulin also was significantly higher in the elderly than in the young (6.8 +/- 1.3 and 3.5 +/- 0.6 mU/L, respectively; P < 0.05), and the postprandial insulin rise was greater in the elderly. Fasting and postprandial ghrelin values did not differ significantly between the 2 groups. Insulin was inversely correlated with hunger and directly correlated with satiety scores. CONCLUSIONS: In healthy elderly, anorexigenic signals prevail over orexigenic signals, and they contribute to prolonged satiety and inhibition of hunger. This condition may lead to a calorie deficit and finally to malnutrition in the elderly.

Delayed postprandial gastric emptying and impaired gallbladder contraction together with elevated cholecystokinin and peptide YY serum levels sustain satiety and inhibit hunger in healthy elderly persons.

BACKGROUND: Altered gastric and cholecystic motility are risk factors for malnutrition in elderly persons, mainly through impaired satiety-appetite rhythm. Contrasting data have been published about this topic. The aim of this study was to evaluate, in healthy elderly participant, postprandial gastric and cholecystic emptying in relation to serum CCK (cholecystokinin) and PYY (peptide YY), as well as satiety and hunger sensations. METHODS: We studied 10 community-dwelling elderly persons, (77 +/- 3 years old) and 9 younger adult persons (32 +/- 8 years old). Using ultrasonography, we measured gastric antrum area and cholecystic volume in fasting condition and after an 800-kcal mixed meal. Time for gastric and cholecystic emptying, and percentage of cholecystic emptying were calculated. Satiety and hunger were evaluated every 30 minutes using visual analogue scales. CCK and PYY serum levels were assayed 30 minutes before and at times 0, 30, 60, 120, and 240 minutes after the meal. RESULTS: Elderly participants showed a longer gastric emptying time compared to younger participants (448 +/- 104 vs 306 +/- 57 minutes, p <.002). Postprandial cholecystic emptying was significantly reduced in the older group (maximum contraction, 69% vs 84%; p <.05). After the meal, CCK and PYY levels showed higher, persistent elevation in elderly participants. In this group, postprandial satiety lasted significantly longer than in younger participants, and hunger was suppressed throughout the postprandial period. Antral area directly correlated with satiety and inversely with hunger. Gallbladder volume inversely correlated to satiety. CONCLUSIONS: This study showed, in a group of healthy elderly people, delayed gastric emptying associated to reduced cholecystic contractility together with higher CCK and PYY serum levels. These modifications facilitated long-lasting satiety and hunger suppression after a meal. This condition may lead to caloric restriction and finally to malnutrition at older ages.

Adipocytokines, fat distribution, and insulin resistance in elderly men and women.

BACKGROUND: The aim of this study was to evaluate the relation between adiponectin and leptin, fat distribution, and insulin resistance in elderly men and women. METHODS: 68 elderly participants (28 men and 40 women) aged 66-77 years, with body mass index (BMI) ranging from 19.83 to 37.18 kg/m2, participated in the study. In all participants, we evaluated BMI, waist and hip circumferences, sagittal abdominal diameter (SAD), fat mass (FM) by dual energy X-ray absorptiometry, fasting and 2-hour glucose, insulin, homeostasis model assessment of insulin resistance (HOMA), leptin, and adiponectin. RESULTS: Elderly women had significantly higher circulating levels of adiponectin and leptin compared to men even after adjusting for age, FM, or waist circumference. In men and women, leptin was positively associated, whereas adiponectin was negatively associated, with BMI, indices of body fat distribution, as well as FM and FM%. Both fasting insulin and HOMA showed significant positive correlation with leptin and negative correlation with adiponectin in both sexes. In a step-wise multiple regression model with HOMA as the dependent variable and age, gender, waist circumference, FM, leptin, and adiponectin as independent variables, waist entered the regression first, explaining 19.7% of HOMA variance, leptin was second, and adiponectin was third, explaining each one an additional 10% of variance. In a multiple linear regression analysis, leptin and adiponectin alone explained up to 38% of HOMA variance. CONCLUSION: Leptin and adiponectin together seem to be strictly related to insulin resistance in elderly people, independently of body fat and body fat distribution.

Identifying sarcopenia in acute care setting patients.

OBJECTIVES: To evaluate the prevalence of sarcopenia by applying European Working Group on Sarcopenia in Older People (EWGSOP) flow chart in an acute care geriatric unit as well as to test a modified version of the EWGSOP diagnostic algorithm combining handgrip and gait speed test to identify subjects with low muscle mass. DESIGN: Observational cohort study. SETTING: Geriatric unit in an academic medical department. PARTICIPANTS: One hundred nineteen acutely ill persons (34.4% female), with mean age 80.4 ± 6.9 years and body mass index 26.3 ± 4.9 kg/m(2). MEASUREMENTS: Assessment of muscle mass by bioimpedence analysis, muscle strength by handheld dynamometer, and gait speed with the 4-meter walking test. RESULTS: Using the EWGSOP classification for sarcopenia, 5.0% presented with sarcopenia and 21.0% with severe sarcopenia. Combining gait speed test and handgrip strength measurement, the highest predictive power in detecting subjects with low muscle mass was observed (sensitivity and specificity, 80.6% and 62.5%, respectively). Subjects presenting with both normal gait speed and handgrip showed normal values of muscle mass as assessed with bioimpedence analysis. By using the ROC method, when the 2 tests were combined, the AUC was statistically higher than when using each test separately (0.740; P = .018). CONCLUSIONS: Our study shows that 1 of 4 patients admitted to the acute care department were recognized to be sarcopenic. When a modifived version of the EWGSOP flow chart, obtained combining both gait speed and handgrip was used, sensitivity and specificity of algorithm to identify subjects with low muscle mass was improved.

Supervised walking groups to increase physical activity in elderly women with and without hypertension: effect on pulse wave velocity.

To date, only a few studies have evaluated the effect of physical activity on PWVcf in the elderly. In the current study, 21 community-dwelling women, with a mean age of 68.19±5.72 years and a mean BMI of 28.63±4.69 kg m(-2), participated in moderate physical activity sessions for 1 h per day and 2 days each week under the supervision of a qualified physical education instructor for a total of 24 weeks. At the beginning of the study, at 3 months and at 6 months, the study participants' body weight, waist circumference, sagittal abdominal diameter (SAD) and body composition by dual energy X-ray absorptiometry (DEXA) were recorded along with the participants' Physical Activity Scale for the Elderly questionnaire. Total low-density-lipoprotein and high-density lipoprotein cholesterol; triglycerides (TGs) and HbA1c; blood pressure (BP); and arterial stiffness, as determined by carotid-femoral and carotid-radial pulse wave velocity (PWVcf, PWVcr), were also assessed. During the follow-up period, the waist and SAD significantly decreased, whereas fat-free mass, BMI and weight did not decrease. A significant decline in TGs was observed. A significant decline in PWVcf, even after adjusting for mean arterial pressure, heart rate triglycerides and waist diameter changes, was observed. In a sub-analysis that examined the effect of physical activity separately in the hypertensive and normotensive subjects, we observed a significant decline in PWVcf in the hypertensive subjects and a nonsignificant tendency in the normotensive subjects. The data showed an association between light aerobic physical activity in the elderly and decreased PWVcf, even after adjusting for changes in systolic BP (SBP), TGs and central adiposity. These results suggest a beneficial effect of moderate physical activity on subclinical vascular damage, particularly in hypertensive subjects.

The quantity of meal fat influences the profile of postprandial hormones as well as hunger sensation in healthy elderly people.

BACKGROUND: In healthy elderly people, reduced appetite and the consequent decrease in food intake has been defined as the "anorexia of aging"; this condition may lead to malnutrition. The aim of this study was to investigate how different compositions of macronutrients affect satiety and hunger signals as well as subjective sensations after meals in healthy elderly subjects. METHODS: Experimental controlled study. Ambulatory healthy community-dwelling subjects evaluation in a single center on 12 elderly subjects, (75.2+/-2 years old) and 12 younger controls (28.2+/-2 years old). Using a visual analogical scale, hunger was evaluated under fasting conditions and at 30-minute intervals for up to 4 hours after two 800-kcal meals, where 20% and 40% of the calories were derived from fat. Serum samples were collected at -30, 60, 120, and 240 minutes to determine the concentrations of GLP-1, acylated and desacylated ghrelin, triglycerides, glucose, and insulin. RESULTS: Serum concentrations of GLP-1 were higher after the 40% fat meal than after the 20% fat meal (P < .01) in the elderly but not in the younger subjects. Acylated to desacylated ratio was lower after the 40% fat meal (P < .05) in the elderly. Only in the older group were triglycerides higher (P < .05), whereas hunger was significantly lower (P < .05) after the 40% fat meal. CONCLUSION: In healthy elderly people relatively large amounts of fat increase the satiety signal from GLP-1 and lower the acylated to desacylated ratio of ghrelin, consequently decreasing hunger. This condition may lead to a reduction in calorie intake.

Relationships between leisure-time physical activity, obesity and disability in elderly men.

BACKGROUND AND AIMS: Relationships have already been shown between leisure-time physical activity, obesity and body composition in young adults. However, this association needs to be confirmed in the elderly. The aim of this study was to investigate the relationship between leisure-time physical activity, obesity, preservation of muscle mass and disability in elderly men. METHODS: Cross-sectional analysis of a sample of 85 community-dwelling men, 68 to 79 years of age. Body mass index (BMI) was used to quantify obesity. Body composition was evaluated using Dual Energy X-ray Absorptiometry. Disability was measured using a modified version of the Activities of Daily Living scale. Leisure-time physical activity was evaluated by a validated self-administered questionnaire. RESULTS: A negative relation between obesity and weekly walking was observed. Walking less than 30 minutes per day was associated with a 2.7 greater probability of being obese (95% CI 1.1-6.7). High-intensity exercise, such as brisk walking or gardening, was inversely correlated with body fat (R = -0.296, p < 0.01) and directly correlated with appendicular skeletal mass (R = 0.238, p < 0.05). The prevalence of disability was the highest (58%) among overweight elderly subjects at the lowest tertile of exercise. Multiple logistic regression selected BMI as a positive predictor and high-intensity exercise as a negative predictor of disability. CONCLUSIONS: Our study shows that, in elderly men, leisure-time physical activity is inversely associated with body fat, BMI, and reported disability, but positively associated with appendicular fat-free mass. The highest prevalence of reported disability was observed in sedentary subjects with BMI higher than 25 kg/m2.

Relationship between leptin levels and bone mineral density in the elderly.

OBJECTIVE: To assess the relationship between circulating leptin levels, bone mineral content and density in the elderly. DESIGN: A cross-sectional study. PATIENTS: A cohort of 92 men and 171 women, with ages ranging from 68 to 75 years, selected as a healthy and normal functioning group, in the city centre of Verona. MEASUREMENTS: Plasma leptin levels were determined in each participant. Body composition was evaluated with dual energy X-ray absorptiometry (DXA). Bone mineral content (BMC) and bone mineral density (BMD) were measured at whole-body, hip and femoral neck level in all subjects. RESULTS: In both men and women a significant relationship between fat mass and whole-body BMC or BMD was found. The strength of this association was consistently reduced after adjustment for plasma leptin. A significant association between circulating leptin levels, whole-body, total hip and femoral neck BMC and BMD was found in both sexes. This association retained the statistical significance after adjustment for fat mass percentage, especially in women. In stepwise multiple linear regression analyses, leptin was shown to be a significant predictor of whole-body, total hip and femoral neck BMC and BMD, independently of age and the percentage of body fat in both sexes. The circulating levels of leptin accounted for a variance in whole-body BMC of 8.9% in men and 18.2% in women, and in whole-body BMD of 10.6% in women. CONCLUSION: Our data show a significant relationship between leptin, bone mineral mass and density in healthy elderly men and women.