Comparison of Narrow-Versus Broad-Spectrum Antibiotics in Elderly Patients With Acute Exacerbations of Chronic Obstructive Pulmonary Disease.

BACKGROUND: Little evidence is available regarding the choice of empiric antibiotic therapy in elderly patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD). The primary objective of this study is to compare the outcomes of elderly patients receiving broad- versus narrow-spectrum antibiotics during hospitalization for AECOPD. DESIGN: A multicenter, retrospective, cohort analysis was performed. Inpatients 65 years and older with a primary discharge diagnosis of AECOPD who received ≥48 hours of antibiotic therapy were included in the study population. Patients were compared based on the spectrum of their antibiotic therapy. Narrow-spectrum antibiotics included: azithromycin, doxycycline, sulfamethoxazole/trimethoprim, or aminopenicillin. The primary outcome was a composite of mechanical ventilation 48 hours after admission, transfer to the intensive care unit 48 hours after admission, 30-day chronic obstructive pulmonary disease (COPD) readmission, and oxygen saturation less than 90% on room air or increased oxygen requirements from baseline 48 hours after admission. RESULTS: Two hundred fifty-three patients were included in this analysis; 127 patients were included in the narrow-spectrum group, and 126 patients were included in the broad-spectrum group. Patient demographics and comorbid conditions were similarly distributed in each group. The incidence of the primary composite outcome occurred in 50 (39.3%) and 60 (47.6%) of patients in the narrow- and broad-spectrum groups, respectively (P = .19). CONCLUSIONS AND RELEVANCE: No difference was found in the primary outcome in inpatients aged ≥65 years with AECOPD who received empiric broad-spectrum or narrow-spectrum antibiotics.

Prevalence, predictors and trends of opioid prescribing for lower back pain in United States emergency departments.

WHAT IS KNOWN AND OBJECTIVE: Current evidence-based guidelines for the treatment of acute low back pain (ALBP) recommend the use of opioid medications only after failure of nonpharmacological therapy, non-steroidal anti-inflammatory drugs and skeletal muscle relaxants and after thorough evaluation of risks and benefits. Despite this recommendation and the state of the opioid epidemic in the United States (US), opioids remain a common drug of choice for ALBP in the emergency department (ED). The purpose of this study was to quantify the prevalence and identify predictors of opioid prescribing for acute lower back pain (ALBP) in emergency departments (EDs) in the United States. METHODS: This was a national, cross-sectional study of the National Hospital Ambulatory Care Survey from 2013-2016. ED visits for patients aged ≥18 years treated for ALBP were included. Patients presenting with specified reasons that an opioid may be indicated were excluded. The primary endpoint was frequency of opioids prescribed. A multivariate logistic regression model identified patient- and provider-level predictors of opioid use. RESULTS AND DISCUSSION: This analysis included 2260 visits for ALBP. Opioids were prescribed in 32.3% of visits. Positive predictors of opioid prescribing were pain score of 7-10 (OR 1.85; 95% CI 1.26-2.70), and patients seen in the Southern (OR 2.53; 95% CI 1.47-4.36) or Western US (OR 2.10; 95% CI 1.19-3.70). Opioids were prescribed less often to patients who received a NSAID or acetaminophen (OR 0.38; 95% CI 0.28-0.52 and OR 0.03; 95% CI 0.01-0.10, respectively). WHAT IS NEW AND CONCLUSION: Opioid prescribing rates for ALBP remain high and the predictors identified demonstrate that this prescribing pattern is not uniformly distributed across the patient and provider characteristics studied.

Evaluation of initial atypical antipsychotic monitoring parameters in children and adolescents.

INTRODUCTION: Atypical antipsychotics (AAPs) are associated with serious cardiometabolic disturbances, including hyperlipidemia, hyperglycemia, and weight gain. The American Academy of Child and Adolescent Psychiatry Practice parameter for the use of AAPs in children and adolescents encourages that the same monitoring schedule as recommended by the American Diabetes Association be applied to the pediatric population. This study assessed adherence to these monitoring recommendations for AAPs in children and adolescents admitted to a community teaching hospital's inpatient child and adolescent psychiatry unit. METHODS: Patients age <18 years were included if therapy was initiated with an AAP during an inpatient admission to the child and adolescent psychiatry unit. Patients were excluded if prescribed an AAP prior to admission or if the AAP was ordered as needed. The presence of the following was collected upon initiation: body mass index (BMI), fasting blood glucose (FBG), blood pressure (BP), fasting lipids, heart rate (HR), waist circumference, electrocardiogram when indicated, and assessment of efficacy and extrapyramidal symptoms (EPS). Any adverse effects and means of mitigation of those adverse effects were also collected. RESULTS: In the 45 patients included, the following monitoring parameters were collected: 91.1% had BMI, 84.4% had FBG, 46.6% had fasting lipids, and 0% had waist circumference recorded. Additionally, 100% of patients had an assessment of efficacy and EPS and BP and HR documented. DISCUSSION: Although this study included a small number of patients, there is area for improvement in obtaining baseline monitoring parameters in children and adolescents initiated on AAPs during an inpatient admission.

Utilization of High-Intensity Statins in Patients at Risk for Cardiovascular Events: A National Cross-Sectional Study.

BACKGROUND: The 2013 American College of Cardiology/American Heart Association cholesterol guidelines, which identified four groups of patients at risk for atherosclerotic cardiovascular disease events, departed from the target-based approach to managing cholesterol. The impact of these guidelines on high-intensity statin use across the United States is unclear. STUDY QUESTION: The primary objective was to evaluate the rate of high-intensity potential (HIP) statin use before and after the 2013 guidelines. The secondary objective was to identify predictors of HIP statin use within the study population. STUDY DESIGN: A national cross-sectional study was conducted using data from the National Ambulatory Medical Care Survey. Office visits involving patients aged 21-75 years where criteria for HIP statin therapy were met were included. Visits involving pregnant patients were excluded. MEASURES AND OUTCOMES: Prescribing trends of HIP statins were measured from National Ambulatory Medical Care Survey data before and after the 2013 guidelines. Multivariate logistic regression identified variables associated with prescribing HIP statins. RESULTS: A total of 48,884 visits were included, representing more than 940 million office visits nationally. HIP statins were listed in 9.5% and 16.5% of visits before and after 2013, respectively (odds ratio [OR] 1.88; 95% confidence interval [CI] 1.62-2.20). The strongest predictors of HIP statin use were antihypertensive use (OR 5.38, 95% CI 4.67-6.20), comorbid hyperlipidemia (OR 2.93, 95% CI 2.62-3.29), Black race (OR 0.63, 95% CI 0.49-0.81), and Hispanic ethnicity (OR 0.65, 95% CI 0.52-0.80). CONCLUSIONS: Prescribing rates for HIP statins increased after the release of the 2013 guidelines. The prescribing rates were lower than expected, especially in Black and Hispanic patients. These observations signify opportunities to improve the quality of care for patients who are at risk for atherosclerotic cardiovascular disease events in the United States.