Implementation of telehealth antimicrobial stewardship through partnership of an academic medical center and a community hospital.

PURPOSE: Small community hospitals often lack the human, financial, and technological resources necessary to implement and maintain successful antimicrobial stewardship programs now required by national regulatory and accrediting bodies. Creative solutions are needed to address this problem. SUMMARY: A 3-stage, quasi-experimental study including patients receiving antibiotics for pneumonia, skin and soft tissue infections, and urinary tract infections at a community hospital in Wisconsin from June 2013 to December 2015 was conducted. Remote telehealth prospective audit and feedback, guideline and order set management, and staff education targeting pharmacists, nurses, and physicians were provided during the 7-month intervention phase; these services were then removed for the postintervention period. Antimicrobial utilization (days of therapy [DOT] per 1,000 patient-days), hospital length of stay, and readmission and 30-day mortality rates were assessed to determine the impact of telehealth services on these outcomes. During the preintervention (baseline), intervention, and postintervention periods, 1,037 patients received antibiotics for the targeted infectious disease conditions. Patient demographics and rates of infectious disease conditions were similar among the different periods. Telehealth antimicrobial stewardship reduced broad-spectrum antibiotic use, including use of imipenem (from 83 to 31 DOT, P < 0.001), levofloxacin (from 123 to 99 DOT, P < 0.001), and vancomycin (from 104 to 85 DOT, P < 0.001), compared to utilization during the baseline period; mean (SD) length of stay also decreased (from 4.6 [2.8] days to 4.2 [2.6] days, P = 0.02). After nonrenewal of telehealth stewardship, vancomycin and piperacillin/tazobactam usage returned to or exceeded baseline levels. CONCLUSION: The partnership between an academic medical center and a small community hospital improved antimicrobial utilization and clinical outcomes. Successful telehealth antimicrobial stewardship models should be explored further as a means to provide optimal patient care.

New pharmacological treatments for methicillin-resistant Staphylococcus aureus infections.

INTRODUCTION: Despite available treatment options for methicillin-resistant Staphylococcus aureus (MRSA), the morbidity and mortality attributed to the diverse infection manifestations of this pathogen remain high. More anti-MRSA agents are needed as options for treatment of these infections. Ideally, these new agents would be rapidly bactericidal for bloodstream clearance in septic patients, have few toxicities, be active against MRSA in biofilms, be easy to administer, and have oral bioavailability. AREAS COVERED: This review focuses on MRSA agents in Phase III trials or antibiotics currently in the market, which are being studied for new indications. For each agent, the antimicrobial potency against MRSA, pharmacokinetic and pharmacodynamic considerations and approved and potential new indications are presented. The role of novel combination therapies is also introduced. EXPERT OPINION: The new lipoglycopeptides oritavancin, telavancin and dalbavancin have the potential to make a large impact on the treatment of MRSA due to unique pharmacokinetic/pharmacodynamic properties and proposed dosing regimens. Other new agents (omadacycline and tedizolid) as well as revisited older agents (fosfomycin and fusidic acid) appear promising but require further study for their potential role. Combination therapy may improve outcomes in patients with high MRSA infection burden or when patient or pathogen factors predict a worse outcome with monotherapy.

Nonprescription medication use in patients with heart failure: assessment methods, utilization patterns, and discrepancies with medical records.

BACKGROUND: The use of over-the-counter products, herbals, and vitamins or supplements (collectively termed "nonprescription medications") is common among individuals with cardiovascular disease. We sought to determine patterns and predictors of nonprescription medication use and assessed whether different survey methodology may result in variable patient reporting of these products. METHODS AND RESULTS: We surveyed 161 patients with heart failure. The first 80 participants were provided a written survey to complete during their clinic appointment, and the next 80 age-matched participants met with study personnel for survey administration via face-to-face interview. Over-the-counter product use was reported by 88% of participants, whereas 34.8% took herbal supplements, and 65.2% took vitamins or supplements. Users of nonprescription medications were older, more likely to have an ischemic etiology, and concomitant chronic conditions. No differences in reporting were noted for patient versus provider-administered surveys. Discrepancies between survey and medical record data were common (40.4%), occurring most frequently with nonprescription aspirin, proton pump inhibitors, magnesium, and acetaminophen. CONCLUSIONS: The majority of study participants used nonprescription medications, and often did not report usage to health care providers. Patient education regarding importance of disclosure of nonprescription medications is crucial, as is consistent querying of use by heart failure providers.

Insulin resistance and incident heart failure the ARIC study (Atherosclerosis Risk in Communities).

OBJECTIVES: This study was designed to assess the relationship between insulin resistance and incident heart failure (HF) in a community-based cohort. BACKGROUND: Diabetes mellitus increases the risk for HF, but the association between insulin resistance and HF in individuals without diabetes is unclear. METHODS: We prospectively analyzed 12,606 participants without diabetes mellitus, prevalent HF, or history of myocardial infarction at baseline (1987 to 1989) from the ARIC (Atherosclerosis Risk in Communities) study. We assessed the relationship between insulin resistance and incident HF using the homeostatic model assessment of insulin resistance (HOMA-IR) equation, adjusting for age, sex, race, body mass index, smoking, hypertension, center, and interim myocardial infarction. We tested for interactions by age, sex, obesity, and race. RESULTS: Participants with insulin resistance, defined as HOMA-IR ≥2.5 (n = 4,810, 39%), were older, more likely female, African American, hypertensive, and had a higher body mass index as compared with those without insulin resistance. There were 1,455 incident HF cases during a median of 20.6 years of follow-up. Insulin resistance defined by this threshold was not significantly associated with an increased risk for incident HF after adjustment (hazard ratio: 1.08, 95% confidence interval: 0.95 to 1.23). However, when analyzed continuously, this relationship was nonlinear, which indicated that risk increased, and was significantly associated with incident HF between HOMA-IR of 1.0 to 2.0, adjusting for baseline covariates; however, values over 2.5 were not associated with additional increased risk in adjusted models. CONCLUSIONS: In a community cohort, insulin resistance, defined by lower levels of HOMA-IR than previously considered, was associated with an increased risk for HF.