Utilization of broad- versus narrow-spectrum antibiotics for the treatment of outpatient community-acquired pneumonia among adults in the United States.

PURPOSE: To characterize antibiotic utilization for outpatient community-acquired pneumonia (CAP) in the United States. METHODS: We conducted a cohort study among adults 18-64 years diagnosed with outpatient CAP and a same-day guideline-recommended oral antibiotic fill in the MarketScan® Commercial Database (2008-2019). We excluded patients coded for chronic lung disease or immunosuppressive disease; recent hospitalization or frequent healthcare exposure (e.g., home wound care, patients with cancer); recent antibiotics; or recent infection. We characterized utilization of broad-spectrum antibiotics (respiratory fluoroquinolone, ß-lactam + macrolide, ß-lactam + doxycycline) versus narrow-spectrum antibiotics (macrolide, doxycycline) overall and by patient- and provider-level characteristics. Per 2007 IDSA/ATS guidelines, we stratified analyses by otherwise healthy patients and patients with comorbidities (coded for diabetes; chronic heart, liver, or renal disease; etc.). RESULTS: Among 263 914 otherwise healthy CAP patients, 35% received broad-spectrum antibiotics (not recommended); among 37 161 CAP patients with comorbidities, 44% received broad-spectrum antibiotics (recommended). Ten-day antibiotic treatment durations were the most common for all antibiotic classes except macrolides. From 2008 to 2019, broad-spectrum antibiotic use substantially decreased from 45% to 19% in otherwise healthy patients (average annual percentage change [AAPC], -7.5% [95% CI -9.2%, -5.9%]), and from 55% to 29% in patients with comorbidities (AAPC, -5.8% [95% CI -8.8%, -2.6%]). In subgroup analyses, broad-spectrum antibiotic use varied by age, geographic region, provider specialty, and provider location. CONCLUSIONS: Real-world use of broad-spectrum antibiotics for outpatient CAP declined over time but remained common, irrespective of comorbidity status. Prolonged duration of therapy was common. Antimicrobial stewardship is needed to aid selection according to comorbidity status and to promote shorter courses.

Validation of algorithms for identifying outpatient infections in MS patients using electronic medical records.

Background Our multiple sclerosis (MS) stakeholder groups expressed concerns about whether MS disease-modifying therapies (DMTs) increase the risk of specific outpatient infections. Validated methods for identifying the risk of these selected outpatient infections in the general population either do not exist, exclude the clinically important possibility of recurrent infections, or are inaccurate, largely because existing studies relied primarily on International Classification of Diseases (ICD) codes to identify infectious outcomes. Additionally, no studies have validated methods among the MS population, where some MS symptoms can be mistaken for infections (e.g., urinary tract infections (UTIs)). Objective To utilize multiple data elements in the electronic health record (EHR) to improve accurate identification of selected outpatient infections in an MS cohort and general population controls. Methods We searched Kaiser Permanente Southern California's EHR based on ICD-9/10 codes for specified outpatient infections from 1/1/2008-12/31/2018 among our MS cohort (n=6000) and 5:1 general population controls matched on age, sex, and race/ethnicity (n=30,010). Random sample chart abstractions from each group were used to identify common coding errors for outpatient pneumonia, upper and lower respiratory tract infection, UTIs, herpetic infections (herpes zoster (HZ), herpes simplex virus (HSV)), fungal infections, otitis media, cellulitis, and influenza. This information was used to define discrete infectious episodes and to identify the algorithm with the highest positive predictive value (PPV) after supplementing the ICD-coded episodes with radiology, laboratory and/or pharmacy data. Results PPVs relying on ICD codes alone were inaccurate, particularly for identifying recurrent herpetic infections (HZ (42%) and HSV (60%)), UTIs (42%) and outpatient pneumonia (20%) in MS patients. Defining and validating episodes improved the PPVs for all the selected infections. The final algorithms' PPVs were 80-100% in MS and 75-100% in the general population, after including dispensed treatments (UTI, herpetic infections and yeast vaginitis), timing of dispensed treatments (UTI, herpetic infections and yeast vaginitis), removal of prophylactic antiviral use (herpetic infections), and inclusion of selected laboratory (UTIs) and imaging results (pneumonia). The only exception was outpatient pneumonia, where PPVs improved but remained ≤70%. There were no significant differences in the PPVs for the final algorithms between the MS and general population. Conclusions Provided herein are accurate and validated algorithms that can be used to improve our understanding of how the risk of recurrent outpatient infections are influenced by MS treatments, MS-related disability, and co-morbidities. Findings from such studies will be important in helping patients and clinicians engage in shared decision-making and in developing strategies to mitigate risks of recurrent infections.

Enterobacterias productoras de betalactamasas de espectro extendido aisladas de pacientes ambulatorios y hospitalizados en un laboratorio privado de Asunción / Extended spectrum β lactamases producing Enterobacteriaceae isolated from outpatient and hospitalized patients in a private laboratory in Asunción, Paraguay

Entre los mecanismos de resistencia en Enterobacteriaceae, las ß-lactamasas de espectro extendido (BLEE) juegan un papel de gran importancia. Estas enzimas confieren resistencia a penicilinas, cefalosporinas de primera, segunda y tercera generación y al aztreonam y por su naturaleza plasmídica se diseminan con mucha facilidad. El presente estudio observacional, descriptivo de corte trasverso tuvo como objetivo determinar la frecuencia de enterobacterias productoras de BLEE en pacientes ambulatorios e internados del Laboratorio San Roque de septiembre a noviembre de 2012. La identificación bacteriana fue realizada por métodos convencionales y la determinación de BLEE por dos métodos fenotípicos; sinergismo de doble disco y el de disco combinado. De los 481 aislados, 88,1% era proveniente de pacientes ambulatorios y 11,9% de internados; resultó predominante Escherichia coli, seguido por Klebsiella pneumoniae. Fue confirmada la producción de BLEE por ambos métodos en 47 enterobacterias, 9,8%. Entre estas K. pneumoniae produjo BLEE con mayor frecuencia 30,8%, seguida de E coli, 6,6%. Todas las cepas productoras de BLEE aisladas en este estudio presentaron actividad cefotaximasa. La frecuencia obtenida es menor a lo reportado en países vecinos, lo que podría deberse a que la mayoría de los aislamientos provinieron de pacientes ambulatorios. Coincidente con estudios realizados en Latinoamérica, K. pneumoniae fue la productora de BLEE con mayor frecuencia y la acción de las BLEEs fue preferentemente sobre las cefotaximas. Si bien la cifra de BLEE encontrada no es alta, se debe insistir en tomar medidas para lograr la reducción de la frecuencia, considerando las graves implicancias que tiene la presencia de esta enzima.

Among resistance mechanisms of enterobacteriaceae, the production of ExtendedSpectrum Betalactamases (ESBL) plays an important role. These enzimes are capable ofinactivating, apart from penicillins, first and second generation cephalosporins, oxyiminocephalosporinsand aztreonam, and because of their plasmidic nature, they spread easily.We conducted a cross-sectional descriptive observational study. The objective was todetermine the frequency of ESBL producing enterobacteriaceae in outpatient andhospitalized patients at the San Roque laboratory from September to November 2012. Microbiological ESBL detection was performed by the double-disk synergy and combineddisk tests. Among 481 clinical isolates of Enterobacteriaceae, 88.1% was from outpatientsand 11.9% from hospitalized patients. Escherichia coli was predominant, followed byKlebsiella pneumoniae. ESBL production was confirmed by both methods in 47enterobacteriaceae, 9.8%. Among these, the most frequent producer of ESBL was K.pneumoniae 30.8% followed by E. coli, 6.6%. All ESBL-producing enterobacteriacea in thisstudy presented cefotaximase activity. The frequency obtained is lower than rates reportedin neighboring countries, which could be explained by the fact that most of the isolates werefrom outpatients. Like other studies in Latin America, ESBL- producing K. pneumoniae wasmore frequent and the action of ESBLs was mainly on cefotaximase. While the number ofESBL found is not high, we should insist on taking steps towards reducing the frequency,considering the serious implications of the presence of this enzyme.