STUDY OBJECTIVES To describe patterns of outpatient antibacterial use among California Medicaid (Medi-Cal) fee-for-service system beneficiaries, and to investigate the influence of demographic factors—age, race-ethnicity, state county, and population density—on those patterns. DESIGN Retrospective analysis of administrative claims data. DATA SOURCE Medi-Cal fee-for-service system claims database. PATIENTS All outpatient Medi-Cal fee-for-service system beneficiaries enrolled between 2006 and 2011 who had at least one systemic antibacterial claim. MEASUREMENTS AND MAIN RESULTS Rates of antibacterial prescribing and the proportion of broad-spectrum antibacterial use were measured over the study period and among age, racial-ethnic and geographic (county) groups. Of the 10,018,066 systemic antibacterial claims selected for analysis, antibacterial prescribing rates decreased from 542 claims/1000 beneficiaries in 2006 to 461 claims/1000 beneficiaries in 2011 (r = –0.971, p = 0.0012; τ-b = –1.00, p = 0.009). Among age groups, children had the highest rate of use (605 claims/1000 beneficiaries, χ2 (2) = 320,000, p < 0.001); among racial-ethnic groups, Alaskan Natives and Native Americans had the highest rate of use (1086/1000 beneficiaries, χ2 (5) = 197,000, p < 0.001). Broad-spectrum antibacterial prescribing increased from 28.1% (95% confidence interval [CI] 28.1–28.2%) to 32.7% (95% CI 32.6–32.8%) over the study period. Senior age groups and Caucasians received the highest proportions of broad-spectrum agents (53.4% [95% CI 52.5–54.3%] and 36.6% [95% CI 36.6–36.7%], respectively). Population density was inversely related to both overall antibacterial use (ρ = –0.432, p = 0.0018) and broad-spectrum antibacterial prescribing (ρ = –0.359, p < 0.001). The rate of prescribing decreased over the study period for all antibacterial classes with the exception of macrolides and sulfonamides. Amoxicillin was the most frequently prescribed agent. CONCLUSION Overall and broad-spectrum antibacterial use in the Medi-Cal fee-for-service program are less than that observed nationally. Significant variations in prescribing exist between age and racial-ethnic groups, and heavily populated areas are associated with both less antibacterial use and less broad-spectrum antibacterial prescribing. Studies are needed to determine the reasons for the observed differences in antibacterial use among demographic groups.

Staphylococcus aureus is a leading cause of bacteremia (1, 2). Even when an individual is appropriately treated, the risk of mortality from S. aureus bacteremia (SAB) is 20 to 40% per episode (3-8). Furthermore, the morbidity from SAB is striking, with 10 to 15% of episodes being complicated by endocarditis or a risk of metastatic disease elsewhere in the body (9, 10). The financial consequences of SAB are also significant, with health care costs ranging from $12,078 to $25,573 per episode of SAB (11-13). Typically, SAB is treated with narrow-spectrum beta-lactam antibiotics for methicillin-susceptible S. aureus (MSSA) isolates and the glycopeptide antibiotic vancomycin for methicillin-resistant S. aureus (MRSA) isolates (14-17). Isolates with vancomycin MICs of Յ2 g/ml are considered susceptible, those with MICs of 4 to 8 g/ml are considered intermediately resistant, and those with MICs of Ͼ8 g/ml are designated resistant (18). The question of whether infection by S. aureus strains with vancomycin MICs of 2 g/ml is associated with worse outcomes has been a topic of much research, although a consensus has not been reached. Compared with research methods such as Epsilometer testing (Etest) or broth microdilution (BMD), automated MIC measurements can be off by 1 dilution in either direction (e.g., a value of 2 g/ml could mean 1 or 4 g/ml if repeated) (19,20), which adds to the deliberation over interpreting study results, although consistency between BMD and Etest results can also vary. In addition, most studies have focused on MRSA, but the role of vancomycin MIC in MSSA infection has not been fully evaluated. A number of studies, including systematic reviews and meta-analyses, have demonstrated increased mortality in the setting of SAB with vancomycin MICs of Ն2.0 g/ml (21-28). Conversely, others have shown an increased risk of mortality in individuals with MICs of Ͻ2.0 g/ml (29-32). In spite of these data, the majority of studies have failed to show any significant increase in the risk of mortality attributable to vancomycin MIC (5,26,. A recent rigorous meta-analysis failed to demonstrate increased 30-day or in-hospital mortality attributable to vancomycin MIC, irrespective of the MIC cutoff that was chosen (1.5, 2.0, 4.0, or 8.0 g/ml) (5). Although valuable, meta-analyses are lim-

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Climate change and ecosystem degradation threaten human health and exacerbate pre‐existing social determinants of health. The prescription drug sector accounts for a significant portion of health care system contributions to greenhouse gas and waste production. Pharmacists are therefore well‐positioned to transform health care toward environmentally sustainable models; however, additional pharmacist education on climate mitigation and sustainable practice is needed. A team of practicing pharmacists and pharmacy students from the United States and Australia aimed to define pharmacists' roles in environmental stewardship by evaluating pre‐existing pharmacy‐led efforts in reducing waste, greenhouse gas emissions, and other health care‐associated environmental impacts. We also describe opportunities for education in pharmacist training as a means to enhance the profession's capacity for environmentally sustainable health care practice and leadership. Information on specific drugs' ecological footprints is increasingly available; pharmacists, as drug information experts, can incorporate sustainability considerations into their drug procurement and prescribing recommendations. Pharmacists also play a critical role in public education about environmentally responsible drug disposal. Finally, we suggest collaborative steps that U.S. organizations involved in pharmacy education could take to ensure that future “practice readiness” includes competence in sustainable health care practices.