Distant metastatic foci of infection in adult patients with diabetic foot - not as rare as we think?: case series and review of the literature.

BACKGROUND: Diabetic foot is one of the common complications of diabetes mellitus. We report clinical and microbiological characteristics and outcomes of cases with distant metastatic foci of infection arising from diabetic foot. METHODS: Retrospective review of adult patients with diabetic foot infection or diabetic foot ulcer who demonstrated distant metastatic foci of infection between August 2017 and December 2019. We performed a literature search of similar cases published until June 2020. RESULTS: Twelve patients with diabetic foot infection or diabetic foot ulcer with distant metastatic foci of infection were identified. The median age of patients was 67.5 years (range 60.5-73.5 years) and 11 males. The most common distant metastatic foci of infection included endocarditis (n = 7) followed by septic arthritis (n = 3) and spine infections (n = 2). Five patients had multiple site and organ involvement. Staphylococcus aureus was the only organism isolated from blood (n = 11), diabetic foot (n = 7), and metastatic foci (n = 8) sources. Three patients died and three had a relapse of distant metastatic foci of infection. Thirty-eight cases were identified in the literature with similar characteristics. CONCLUSIONS: Prevalence of distant metastatic foci of infection in adult patients with diabetic foot and burden of illness, in terms of mortality, morbidity, and length of hospital stay, appears to be underreported in the literature. A large prospective study is needed to assess the true prevalence of complications, associated risk factors, outcomes and prognostic factors.

Features of a mobile health intervention to manage chronic obstructive pulmonary disease: a qualitative study.

BACKGROUND: The use of mobile health (mHealth) interventions has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes. Further research is needed to determine which mHealth features are required to potentially enhance COPD self-management. AIM: The aim of this study was to explore the potential features of an mHealth intervention for COPD management with healthcare providers (HCPs) and patients with COPD. It could inform the development and successful implementation of mHealth interventions for COPD management. METHODS: This was a qualitative study. We conducted semi-structured individual interviews with HCPs, including nurses, pharmacists and physicians who work directly with patients with COPD. Interviews were also conducted with a diverse sample of patients with COPD. Interview topics included demographics, mHealth usage, the potential use of medical devices and recommendations for features that would enhance an mHealth intervention for COPD management. RESULTS: A total of 40 people, including nurses, physicians and pharmacists, participated. The main recommendations for the proposed mHealth intervention were categorised into two categories: patient interface and HCP interface. The prevalent features suggested for the patient interface include educating patients, collecting baseline data, collecting subjective data, collecting objective data via compatible medical devices, providing a digital action plan, allowing patients to track their progress, enabling family members to access the mHealth intervention, tailoring the features based on the patient's unique needs, reminding patients about critical management tasks and rewarding patients for their positive behaviours. The most common features of the HCP interface include allowing HCPs to track their patients' progress, allowing HCPs to communicate with their patients, educating HCPs and rewarding HCPs. CONCLUSION: This study identifies important potential features so that the most effective, efficient and feasible mHealth intervention can be developed to improve the management of COPD.The reviews of this paper are available via the supplemental material section.

Review of high dose vancomycin in the treatment of Clostridioides difficile infection.

BACKGROUND: Guidelines recommend oral vancomycin as first-line therapy for Clostridioides difficile infection. Guideline recommendations vary regarding dosing of vancomycin. Our aim was to summarize the current evidence on the efficacy and adverse effects of high dose oral and vancomycin retention enema (>500 mg/day) for the treatment of C. difficile infection. METHODS: We searched clinical studies and major guidelines in the English language using MEDLINE, the Cochrane Library and Embase from 1985 until 15 April 2020. RESULTS: No evidence supports the use of high dose oral vancomycin in the treatment of severe C. difficile infection. Weak evidence from observational studies supports the use of high dose oral vancomycin in addition to intravenous metronidazole and high dose vancomycin retention enema in fulminant C. difficile infection. Vancomycin retention enema can be used in severe C. difficile infection when oral administration is not possible, or in conditions when the oral formulation cannot reach the colon such as Hartman's pouch, ileostomies, or colon diversions. CONCLUSIONS: The dosing schedules for oral vancomycin and vancomycin enemas are not clearly defined due to widely varying results in clinical studies. Large, comparative multicenter trials are urgently needed to define the role of high dose vancomycin in C. difficile infection.

Perceptions of Patients Regarding Mobile Health Interventions for the Management of Chronic Obstructive Pulmonary Disease: Mixed Methods Study.

BACKGROUND: Using a mobile health (mHealth) intervention consisting of a smartphone and compatible medical device has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes while mitigating health care costs. OBJECTIVE: This study aims to describe the demographics, use, and access to smartphones of patients with COPD. It also aims to explore and develop an understanding of potential facilitators and barriers that might influence patients using mHealth interventions for COPD management. METHODS: This was an explanatory, sequential mixed methods study. Patients who attended respirology clinics completed a questionnaire on technology access and use. We conducted semistructured individual interviews with the patients. Interview topics included the following: demographics, mHealth use, perceptions toward challenges of mHealth adoption, factors facilitating mHealth adoption, and preferences regarding features of mHealth interventions for COPD management. RESULTS: A total of 100 adults completed the survey but 22 participants were excluded because they were not diagnosed with COPD. Of these, 10 patients with COPD participated in the interview. The quantitative component revealed that many patients with COPD owned a mobile phone, but only about one-fourth of the participants (18/77, 23%) owned a smartphone. The likelihood of owning a smartphone was not associated with age, sex, marital status, or geographical location, but patients with high educational status were more likely to own a smartphone. The qualitative component found that patients with COPD, in general, had a positive attitude toward mHealth adoption for COPD management, but several facilitators and barriers were identified. The main facilitators of mHealth adoption are possible health benefits for patients, ease of use, educating patients, and credibility. Alternatively, the barriers to adoption are technical issues, lack of awareness, potential limited uptake from older adults, privacy and confidentiality issues, finances, and lack of interest in mHealth. CONCLUSIONS: It is important to understand the perceptions of patients with COPD regarding the adoption of innovative mHealth interventions for COPD management. This study identifies some potential facilitators and barriers that may inform the successful development and implementation of mHealth interventions for COPD management.

Perceptions of Health Care Providers Regarding a Mobile Health Intervention to Manage Chronic Obstructive Pulmonary Disease: Qualitative Study.

BACKGROUND: Using a mobile health (mHealth) intervention, consisting of a smartphone and compatible medical device, has the potential to enhance chronic obstructive pulmonary disease (COPD) treatment outcomes while mitigating health care costs. OBJECTIVE: The aim of this study was to explore the potential facilitators and barriers among health care providers (HCPs) regarding the use of mHealth interventions for COPD management. METHODS: This was a qualitative study. Semistructured individual interviews were conducted with HCPs, including nurses, pharmacists, and physicians who work directly with patients with COPD. A flexible prompts guide was used to facilitate discussions. Interview topics included the following: demographics, mHealth usage, perceptions toward challenges of mHealth adoption, factors facilitating mHealth adoption, and preferences regarding features of the mHealth intervention for COPD management. Interviews were conversational in nature, and items were not asked verbatim or in the order presented. The interviews were transcribed verbatim and compared against the digital recordings to ensure the accuracy of the content. After creating a codebook for analysis, 2 researchers independently coded the remaining interview data using pattern coding. They discussed commonalities and differences in coding until a consensus was reached. RESULTS: A total of 30 nurses, physicians, and pharmacists participated. The main facilitators to mHealth adoption are possible health benefits for patients, ease of use, educating patients and their HCPs, credibility, and reducing cost to the health care system. Alternatively, the barriers to adoption are technical issues, privacy and confidentiality issues, lack of awareness, potential limited uptake from the elderly, potential limited connection between patients and HCPs, and finances. CONCLUSIONS: It is important to understand the perceptions of HCPs regarding the adoption of innovative mHealth interventions for COPD management. This study identifies some potential facilitators and barriers that may inform the successful development and implementation of mHealth interventions for COPD management.

The Iterative Convergent Design for Mobile Health Usability Testing: Mixed Methods Approach.

Although patients express an interest in using mobile health (mHealth) interventions to manage their health and chronic conditions, many current mHealth interventions are difficult to use. Usability testing is critical for the success of novel mHealth interventions. Researchers recognize the utility of using qualitative and quantitative approaches for usability testing, but many mHealth researchers lack the awareness of integration approaches from advances in mixed methods research that can add value to mHealth technology. As efficient usability testing proceeds iteratively, we introduce a novel mixed methods design developed specifically for mHealth researchers. The iterative convergent mixed methods design involves simultaneous qualitative and quantitative data collection and analysis that continues cyclically through multiple rounds of mixed methods data collection and analysis until the mHealth technology under evaluation is found to work to the satisfaction of the researcher. In cyclical iterations, early development is more qualitatively driven but progressively becomes more quantitatively driven. Using this design, mHealth researchers can leverage mixed methods integration procedures in the research question, data collection, data analysis, interpretation, and dissemination dimensions. This study demonstrates how the iterative convergent mixed methods design provides a novel framework for generating unique insights into multifaceted phenomena impacting mHealth usability. Understanding these practices can help developers and researchers leverage the strengths of an integrated mixed methods design.

How Two Small Pharmacy Schools' Competency Standards Compare with an International Competency Framework and How Well These Schools Prepare Students for International Placements.

International standards of pharmacy curricula are necessary to ensure student readiness for international placements. This paper explores whether curricula from two pharmacy programs, in Australia and Canada, are congruent with international standards and if students feel prepared for international placements. Nationally prescribed educational standards for the two schools were compared to each other and then against the International Pharmaceutical Federation (FIP) Global Competency Framework. Written student reflections complemented this analysis. Mapping results suggested substantial agreement between the FIP framework and Australia and Canada, with two gaps being identified. Moreover, the students felt their programs prepared them for their international placements. Despite differences in countries, pharmacy programs, and health-systems all students acclimatized to their new practice sites. Implications are that if pharmacy programs align well with FIP, pharmacists should be able to integrate and practise in other jurisdictions that also align with the FIP. This has implications for the mobility of pharmacy practitioners to countries not of their origin of training.

Validation of a Cystic Fibrosis Medication Knowledge Questionnaire.

Low adherence to cystic fibrosis (CF) treatment is associated with poor health outcomes, while knowledge of the disease and medication regimen can positively influence adherence. This study's purpose was to develop and validate a questionnaire to help determine CF medication knowledge of pediatric patients and caregivers. Our questionnaire had 37 items: 22 selected-response and 15 open-response questions. We used validation processes from the Standards for Educational and Psychological Testing. CF experts analyzed validity evidence based on content. Then, the questionnaire was field tested with 17 pediatric patients and 18 caregivers. The correlation between age and medication knowledge was medium (r = .33), but was not significant (P = .189). Cronbach's α for the overall test was .84. Participants thought the questionnaire was important and suitable, with a few minor suggestions to improve wording. Strong validity evidence indicates the questionnaire could be used to assess medication knowledge and allow more personalized education to improve adherence.

Effectiveness of a pharmacist-driven intervention in COPD (EPIC): study protocol for a randomized controlled trial.

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) are often nonadherent with medications and have poor inhaler technique. Community pharmacists can help to improve health-related quality of life and overall outcomes in patients with COPD. We aim to measure the effectiveness of a systematic, pharmacist-driven intervention on patients with diagnosed COPD. METHODS/DESIGN: This pragmatic, parallel-group, cluster randomized controlled trial is designed to determine the effectiveness of a multifactorial, pharmacist-led intervention on medication adherence, inhaler technique, health-related quality of life, health care resource utilization including COPD exacerbations, and use of medications. Participating pharmacies in Newfoundland and Labrador (NL), Canada will be randomly assigned to either the intervention or the control group. The intervention group will deliver an enhanced form of care that emphasizes COPD management. The control group will provide usual care and a COPD education pamphlet. Included patients will be aged 40 years or older, have a physician-confirmed diagnosis of COPD, and be able to answer questionnaires in English. The primary outcomes are the between-group difference in the change from baseline to 6 months in medication adherence using the Medication Possession Ratio (MPR) and the Morisky Medication Adherence Scale (MMAS-8). The secondary outcomes are also measured from baseline to 6 months, and include the proportion of patients with a clinically significant change in adherence, the proportion of patients defined as having "good adherence," the mean MPR between groups, quality of life as measured by the St. George's Respiratory Questionnaire, medication inhalation technique using a pharmacist-scored checklist, health care resource utilization and antibiotic and orally administered corticosteroid use for COPD exacerbations. Differences between groups will be analyzed at the individual patient level while controlling for clustering effect. DISCUSSION: A pharmacist-led COPD intervention has the potential to improve patient medication adherence, thus increasing quality of life, possibly decreasing pulmonary exacerbations and reducing utilization of acute health care resources. Methods and results taken from this study could be used to enhance the delivery of COPD care by community pharmacists in a real-world setting. This would serve to enhance COPD population health and quality of life. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) ISRCTN78138190 , registered on 3 February 2016.

The Effect of Smartphone Interventions on Patients With Chronic Obstructive Pulmonary Disease Exacerbations: A Systematic Review and Meta-Analysis.

BACKGROUND: The prevalence and mortality rates of chronic obstructive pulmonary disease (COPD) are increasing worldwide. Therefore, COPD remains a major public health problem. There is a growing interest in the use of smartphone technology for health promotion and disease management interventions. However, the effectiveness of smartphones in reducing the number of patients having a COPD exacerbation is poorly understood. OBJECTIVE: To summarize and quantify the association between smartphone interventions and COPD exacerbations through a comprehensive systematic review and meta-analysis. METHODS: A comprehensive search strategy was conducted across relevant databases (PubMed, Embase, Cochrane, CINHA, PsycINFO, and the Cochrane Library Medline) from inception to October 2015. We included studies that assessed the use of smartphone interventions in the reduction of COPD exacerbations compared with usual care. Full-text studies were excluded if the investigators did not use a smartphone device or did not report on COPD exacerbations. Observational studies, abstracts, and reviews were also excluded. Two reviewers extracted the data and conducted a risk of bias assessment using the US Preventive Services Task Force quality rating criteria. A random effects model was used to meta-analyze the results from included studies. Pooled odds ratios were used to measure the effectiveness of smartphone interventions on COPD exacerbations. Heterogeneity was measured using the I(2)statistic. RESULTS: Of the 245 unique citations screened, 6 studies were included in the qualitative synthesis. Studies were relatively small with less than 100 participants in each study (range 30 to 99) and follow-up ranged from 4-9 months. The mean age was 70.5 years (SD 5.6) and 74% (281/380) were male. The studies varied in terms of country, type of smartphone intervention, frequency of data collection from the participants, and the feedback strategy. Three studies were included in the meta-analysis. The overall assessment of potential bias of the studies that were included in the meta-analysis was "Good" for one study and "Fair" for 2 studies. The pooled random effects odds ratio of patients having an exacerbation was 0.20 in patients using a smartphone intervention (95% CI 0.07-0.62), a reduction of 80% for smartphone interventions compared with usual care. However, there was moderate heterogeneity across the included studies (I(2)=59%). CONCLUSION: Although current literature on the role of smartphones in reducing COPD exacerbations is limited, findings from our review suggest that smartphones are useful in reducing the number of patients having a COPD exacerbation. Nevertheless, using smartphones require synergistic strategies to achieve the desired outcome. These results should be interpreted with caution due to the heterogeneity among the studies. Researchers should focus on conducting rigorous studies with adequately powered sample sizes to determine the validity and clinical utility of smartphone interventions in the management of COPD.

Community-Acquired Pneumonia in Patients With Diabetes Mellitus: Predictors of Complications and Length of Hospital Stay.

BACKGROUND: The primary objective of the study was to determine factors associated with complications and length of hospital stay (LOS) in hospitalized adult patients with diabetes along with community-acquired pneumonia (CAP). CAP is a common infection in patients with diabetes mellitus and is associated with a significant mortality and morbidity. MATERIALS AND METHODS: This is a retrospective cohort study of 215 adult patients with diabetes who were admitted with CAP. A multivariate logistic and Cox regression analysis were used to assess factors associated with complications and LOS of CAP, respectively. RESULTS: During the follow-up period from admission until discharge, 94 patients (43.7%) developed complications. Respiratory failure was the most common complication (43.6%). The average LOS of study cohort was 9.47 days. In the multivariate analysis, complications of CAP were associated with time to first dose of appropriate antibiotic therapy >8 hours since triage at emergency department (ED) (odds ratio = 3.16; 95% CI: 1.58-6.32; P = 0.001) and pneumonia severity index score >90 (odds ratio = 3.52; 95% CI: 1.45-8.53; P = 0.005). In the multivariate Cox regression analysis, time to first dose of appropriate antibiotic therapy >8 hours since triage at ED (hazard ratio [HR] = 0.56, P = 0.01), pneumonia severity index score >90 (HR = 0.62, P = 0.01), presence of complications (HR = 0.53, P = 0.002), duration of antibiotics (HR = 0.90, P ≤ 0.0001) and duration of symptoms prior presentation to ED (HR = 0.96, P = 0.04) were independently determinants of LOS. CONCLUSIONS: Delayed administration of appropriate antibiotic therapy at ED and moderate-to-severe pneumonia were associated with both increased risk of complications and prolonged LOS in hospitalized adult patients with diabetes along with CAP.

Patients' and physicians' satisfaction with a pharmacist managed anticoagulation program in a family medicine clinic.

BACKGROUND: A pharmacist managed anticoagulation service was initiated in a multi-physician family medicine clinic in December 2006. In order to determine the patient and physician satisfaction with the service, a study was designed to describe the patients' satisfaction with the warfarin education and management they received from the pharmacist, and to describe the physicians' satisfaction with the level of care provided by the pharmacist for patients taking warfarin. A self-administered survey was completed by both eligible patients receiving warfarin and physicians prescribing warfarin between December 2006 and May 2008. The patient survey collected information on patient demographics, satisfaction with warfarin education and daily warfarin management. The physician survey collected data about the satisfaction with patient education and daily anticoagulation management by the pharmacist. RESULTS: Seventy-six of 94 (81%) patients completed the survey. Fifty-nine percent were male with a mean age of 65 years (range 24-90). Ninety-six percent agreed/strongly agreed the pharmacist did a good job teaching the importance of warfarin adherence, the necessity of INR testing and the risks of bleeding. Eighty-five percent agreed/strongly agreed the risk of blood clots was well explained, 79% felt the pharmacist did a good job teaching about dietary considerations and 77% agreed/strongly agreed the pharmacist explained when to see a doctor. All patients felt the pharmacist gave clear instructions on warfarin dosing and INR testing. Four of nine physicians (44%) completed the survey. All agreed/strongly agreed the pharmacist was competent in the care provided, were confident in the care their patients received, would like the pharmacist to continue the service, and would recommend this program to other clinics. CONCLUSIONS: Patients and family physicians were satisfied with the pharmacist managed anticoagulation program and recommended continuation of the program. These results support the role of the pharmacist in the management of anticoagulation in a multi-physician family medicine clinic.

Alignment of learning objectives and assessments in therapeutics courses to foster higher-order thinking.

OBJECTIVE: To determine whether national educational outcomes, course objectives, and classroom assessments for 2 therapeutics courses were aligned for curricular content and cognitive processes, and if they included higher-order thinking. METHOD: Document analysis and student focus groups were used. Outcomes, objectives, and assessment tasks were matched for specific therapeutics content and cognitive processes. Anderson and Krathwohl's Taxonomy was used to define higher-order thinking. Students discussed whether assessments tested objectives and described their thinking when responding to assessments. RESULTS: There were 7 outcomes, 31 objectives, and 412 assessment tasks. The alignment for content and cognitive processes was not satisfactory. Twelve students participated in the focus groups. Students thought more short-answer questions than multiple choice questions matched the objectives for content and required higher-order thinking. CONCLUSION: The alignment analysis provided data that could be used to reveal and strengthen the enacted curriculum and improve student learning.

Pharmacist and physician views on collaborative practice: Findings from the community pharmaceutical care project.

BACKGROUND: Strong working relationships between pharmacists and physicians are needed to optimize patient care. Understanding attitudes and barriers to collaboration between pharmacists and physicians may help with delivery of primary health care services. The objective of this study was to capture the opinions of family physicians and community pharmacists in Newfoundland and Labrador (NL) regarding collaborative practice. METHODS: Two parallel surveys were offered to all community pharmacists and family physicians in NL. Surveys assessed the following: attitudes and experience with collaborative practice, preferred communication methods, perceived role of pharmacists, areas for more collaboration and barriers to collaborative practice. Results for both groups were analyzed separately, with comparisons between groups to compare responses with similar questions. RESULTS: Survey response rates were 78.6% and 7.1% for pharmacists and physicians, respectively. Both groups overwhelmingly agreed that collaborative practice could result in improved patient outcomes and agreed that major barriers were lack of time and compensation and the need to deal with multiple pharmacists/physicians. Physicians indicated they would like more collaboration for insurance approvals and patient counselling, while pharmacists want to assist with identifying and managing patients' drug-related problems. Both groups want more collaboration to improve patient adherence. CONCLUSION: Both groups agree that collaborative practice can positively affect patient outcomes and would like more collaboration opportunities. However, physicians and pharmacists disagree about the areas where they would like to collaborate to deliver care. Changes to reimbursement models and infrastructure are needed to facilitate enhanced collaboration between pharmacists and physicians in the community setting.

Risk factors of cellulitis treatment failure with once-daily intravenous cefazolin plus oral probenecid.

OBJECTIVES: Once-daily intravenous cefazolin with probenecid is used commonly to treat cellulitis. The primary objective of this study was to determine the risk factors of treatment failure with this regimen. METHODS: This was a retrospective cohort study of adult outpatients with cellulitis who were initially treated with once-daily intravenous cefazolin plus probenecid. Treatment failure is defined as inadequate improvement that necessitates either hospital admission or a change in antibiotic therapy to a different intravenous regimen. A stepwise logistic regression analysis was performed to determine the risk factors for regimen failure. RESULTS: From January 2003 to December 2008, 159 patients with cellulitis were initially treated with once daily intravenous cefazolin plus probenecid. Thirty-five (22%) patients had treatment failure. The treatment for 53% (9/17) of the patients with a history of chronic venous disease (CVD) failed, whereas the treatment for 18% (26/142) of patients without CVD failed (P = 0.001). Multivariate analysis identified the presence of CVD as the only risk factor associated with treatment failure (odds ratio 4.4, 95% confidence interval 1.5-13; P = .007). CONCLUSIONS: Patients with cellulitis and CVD who are being treated with once-daily intravenous cefazolin plus probenecid should be monitored closely for treatment failure.

Comparison of pharmacist managed anticoagulation with usual medical care in a family medicine clinic.

BACKGROUND: The beneficial outcomes of oral anticoagulation therapy are dependent upon achieving and maintaining an optimal INR therapeutic range. There is growing evidence that better outcomes are achieved when anticoagulation is managed by a pharmacist with expertise in anticoagulation management rather than usual care by family physicians. This study compared a pharmacist managed anticoagulation program (PC) to usual physician care (UC) in a family medicine clinic. METHODS: A retrospective cohort study was carried out in a family medicine clinic which included a clinical pharmacist. In 2006, the pharmacist assumed anticoagulation management. For a 17-month period, the PC group (n = 112) of patients on warfarin were compared to the UC patients (n = 81) for a similar period prior to 2006. The primary outcome was the percentage of time patients' INR was in the therapeutic range (TTR). Secondary outcomes were the percentage of time in therapeutic range within ± 0.3 units of the recommended range (expanded TTR) and percentage of time the INR was >5.0 or <1.5. RESULTS: The baseline characteristics were similar between the groups. Fifty-five percent of the PC group was male with a mean age of 67 years; 51% of the UC group was male with a mean age of 71 years. The most common indications for warfarin in both groups were atrial fibrillation, mechanical heart valves and deep vein thrombosis. The TTR was 73% for PC and 65% for UC (p < 0.0001). The expanded TTR for PC was 91% and 85% for UC (p < 0.0001). The percentage of time INR values were <1.5 was 0.7% for PC patients and 1.9% for UC patients (p < 0.0001), and >5 were 0.3% for PC patients and 0.1% for UC (p < 0.0001). CONCLUSION: The pharmacist-managed anticoagulation program within a family practice clinic compared to usual care by the physicians achieved significantly better INR control as measured by the percentage of time patients' INR values were kept in both the therapeutic and expanded range. Based on the results of this study, a collaborative family practice clinic using pharmacists and physicians may be an effective model for anticoagulation management with these results verified in future prospective randomized studies.

Management of complicated urinary tract infections in the era of antimicrobial resistance.

Complicated urinary tract infections (cUTIs) are a major cause of hospital admissions and are associated with significant morbidity and health care costs. Patients presenting with a suspected UTI should be screened for the presence of complicating factors, such as anatomic and functional abnormalities of the genitourinary tract. In the setting of cUTIs, the etiology and susceptibility of the causative organism is not predictable; therefore, when infection is suspected, patients should undergo a urinalysis in addition to culture and sensitivity testing. Although not warranted in all cases of complicated pyelonephritis, blood cultures are appropriate in some clinical settings. With the increased prevalence of antimicrobial resistance, and the lack of well-designed clinical trials, treatment of cUTIs can be challenging for clinicians. Although resistant organisms are not always implicated as the causative agent, all patients with cUTIs should be assessed for predisposing risk factors. Consideration of an optimal antimicrobial agent should be based on local resistance patterns, patient-specific factors, including anatomic site of infection and severity of disease, pharmacokinetic and pharmacodynamic principles, and cost. Resistance to first-line antimicrobial agents, including fluoroquinolones, has become increasingly common in Escherichia coli. Fluoroquinolones should not be used as a first-line option for empiric treatment of serious cUTIs, especially when patients exhibit risk factors for harboring a resistant organism, such as previous or recent use of fluoroquinolones. Fluoroquinolones, trimethoprim-sulfamethoxazole, and nitrofurantoin are still appropriate empiric options for mild lower cUTIs. However, empiric treatment for serious cUTIs, where risk factors for resistant organisms exist, should include broad-spectrum antibiotics such as carbapenems or piperacillin-tazobactam. Once organisms and susceptibilities are identified, treatment should be targeted accordingly. Nitrofurantoin and fosfomycin have limited utility in the setting of cUTIs and should be reserved as alternative treatment options for lower cUTIs following confirmation of the causative organism. Aminoglycosides, tigecycline, and polymyxins can be used for the treatment of serious cUTIs when first-line options are deemed to be inappropriate or patients fail therapy. The duration of treatment for cUTIs has not been well established; however, treatment durations can range from 1 to 4 weeks based on the clinical situation.

Use of evidence-based therapy at discharge for patients with acute myocardial infarction: retrospective audit of medical records.

BACKGROUND: Various guidelines are available outlining optimal therapy for patients with acute myocardial infarction. Canadian institutions providing care for such patients have been encouraged to evaluate their care processes using specific indicators. OBJECTIVE: To determine the proportion of patients with acute myocardial infarction discharged from a single health authority for whom acetylsalicylic acid (ASA), adrenergic ß-receptor antagonists (ß-blockers), angiotensin-converting enzyme (ACE) inhibitors, or 3-hydroxy-3-methylglutaryl coenzyme A (HMG-CoA) reductase inhibitors (statins) had been prescribed. METHODS: Patients treated over a 12-month period (April 1, 2004, to March 31, 2005) for whom the most responsible diagnosis was acute myocardial infarction were eligible for inclusion in this review. Retrieved data included diagnosis, demographic information, comorbidities, and medications at the time of admission and discharge. Rates of discharge prescribing for the 4 drug classes were calculated for all patients and for "ideal" patients (those without documented contraindications). Rates were compared with published benchmark values. RESULTS: Medical records for a total of 346 eligible patients were reviewed. Mean age was 65.3 years (standard deviation 13.4 years), and 226 (65.3%) of the patients were male. The coded diagnosis was ST-elevation myocardial infarction for 91 patients (26.3%), non-ST-elevation myocardial infarction for 164 (47.4%), and myocardial infarction not specified for 91 (26.3%). For "ideal" patients, the prescribing rates were 99.0% (308 of 311 patients) for ASA, 96.3% (310 of 322 patients) for ß-blockers, 90.4% (264 of 292 patients) for ACE inhibitors, and 88.8% (278 of 313 patients) for statins. CONCLUSIONS: Rates of prescribing of ASA, ß-blockers, ACE inhibitors, and statins for "ideal" patients discharged after treatment for acute myocardial infarction exceeded the published Canadian benchmark rates (≥ 90% for ASA, ≥ 85% for ß-blockers and ACE inhibitors, ≥ 70% for statins).