No abstract

Summary Background Modification of empirical antimicrobials when warranted by culture results or clinical signs is recommended to control antimicrobial overuse and resistance. We aimed to assess the frequency with which patients were started on empirical antimicrobials, characteristics of the empirical regimen and the clinical characteristics of patients at the time of starting antimicrobials, patterns of changes to empirical therapy at different timepoints, and modifiable factors associated with changes to the initial empirical regimen in the first 5 days of therapy. Methods We did a chart review of adult inpatients receiving one or more antimicrobials in six US hospitals on 4 days during 2009 and 2010. Our primary outcome was the modification of antimicrobial regimen on or before the 5th day of empirical therapy, analysed as a three-category variable. Bivariate analyses were used to establish demographic and clinical variables associated with the outcome. Variables with p values below 0.1 were included in a multivariable generalised linear latent and mixed model with multinomial logit link to adjust for clustering within hospitals and accommodate a non-binary outcome variable. Findings Across the six study sites, 4119 (60%) of 6812 inpatients received antimicrobials. Of 1200 randomly selected patients with active antimicrobials, 730 (61%) met inclusion criteria. At the start of therapy, 220 (30%) patients were afebrile and had normal white blood cell counts. Appropriate cultures were collected from 432 (59%) patients, and 250 (58%) were negative. By the 5th day of therapy, 12·5% of empirical antimicrobials were escalated, 21·5% were narrowed or discontinued, and 66·4% were unchanged. Narrowing or discontinuation was more likely when cultures were collected at the start of therapy (adjusted OR 1·68, 95% CI 1·05–2·70) and no infection was noted on an initial radiological study (1·76, 1·11–2·79). Escalation was associated with multiple infection sites (2·54, 1·34–4·83) and a positive culture (1·99, 1·20–3·29). Interpretation Broad-spectrum empirical therapy is common, even when clinical signs of infection are absent. Fewer than one in three inpatients have their regimens narrowed within 5 days of starting empirical antimicrobials. Improved diagnostic methods and continued education are needed to guide discontinuation of antimicrobials. Funding US Centers for Disease Control and Prevention, Division of Healthcare Quality Promotion; Robert Wood Johnson Foundation; US Department of Veterans Administration; US Department of Homeland Security.

The application of multilocus sequence typing has uncovered the emergence of an epidemic clone of E. faecium ST203 that appears to have acquired the vanB locus and has caused a sustained outbreak of VRE bacteremia.

Objective For most common infections requiring hospitalization, antibiotic treatment is completed after hospital discharge. Post-discharge therapy is often unnecessarily broad-spectrum and prolonged. We developed an intervention to improve antibiotic selection and shorten treatment durations. Design Single center, quasi-experimental retrospective cohort study. Methods Patients prescribed oral antibiotics at hospital discharge before (July 2012 – June 2013) and after (October 2014 – February 2015) an intervention consisting of: 1) institutional guidance for oral step-down antibiotic selection and duration of therapy, and 2) pharmacy audit of discharge prescriptions with real-time prescribing recommendations to providers. The primary outcomes were total prescribed duration of therapy and use of antibiotics with broad gram-negative activity (fluoroquinolones or amoxicillin-clavulanate). Results 300 cases from the pre-intervention period and 200 from the intervention period were included. Compared with the pre-intervention period, use of antibiotics with broad gramnegative activity decreased during the intervention (51% vs 40%, p = 0.02), particularly fluoroquinolones (38% vs 25%, p = 0.002). The difference in total duration of therapy did not reach statistical significance (10 days [interquartile range (IQR) 7–13] vs 9 [IQR 6–13], p = 0.13); however, the duration prescribed at discharge declined from 6 days (IQR 4–10) to 5 (IQR 3–7) (p = 0.003). During the intervention, there was a non-significant increase in the overall appropriateness of discharge prescriptions (52% vs 66%, p = 0.15). Conclusions A multifaceted intervention to optimize antibiotic prescribing at hospital discharge was associated with less frequent use of antibiotics with broad gram-negative activity and shorter post-hospital treatment durations.

Three experiments compared the effects of lesioning areas of thalamus, cortex, and the hippocampal system on delayed matching (DMTS) and nonmatching (DNMTS) to sample. Temporal decay was measured by comparing performances at different retention intervals (RIs) for rats trained to stability. Lesions of the lateral-internal medullary lamina site in thalamus and the medial wall area in frontal cortex produced impairments that were significantly greater than for lesions of the mediodorsal nucleus in thalamus, the fornix, or the dorsal hippocampus. The effects of lesions on temporal decay differed depending on how RIs were manipulated. When RIs were manipulated within training sessions, the DMTS and DNMTS impairments were delay independent (i.e., none of the lesions increased the rate of temporal decay). When RIs were manipulated between sessions, thalamic lesions were associated with an increase in the rate of temporal decay of DNMTS.

SummaryWhat is known and objective: Proton pump inhibitor (PPI) prescribing may often be inappropriate and expose patients to a risk of adverse effects, while incurring unnecessary healthcare expenditure. Our objective was to determine PPI usage in Australia since 2002 and review international studies investigating inappropriate PPI prescribing, including those that discussed interventions to address this issue. Methods: Australian Pharmaceutical Benefits Scheme (PBS) and RepatriationPharmaceutical Benefits Scheme (RPBS) data were analysed. A narrative literature review relevant to the objective was conducted. Time series analysis was also used to examine the trend of reported PPI appropriate use across the international studies included in this review. Results and discussion K E Y W O R D Sdeprescribing, gastro-oesophageal reflux, PPI, prescribing patterns, proton pump inhibitor

Blood transfusion was associated with SSI after TAH in our population. As it is a modifiable risk factor, larger multi-center studies are needed to confirm this result and determine appropriate transfusion thresholds.

➤ The number of patients with end-stage osteoarthritis is increasing, and treatment with hip and knee arthroplasty is expected to increase over the next several decades. ➤ Dental disease has long been anecdotally associated with increased periprosthetic joint infections, although case-control studies do not support this relationship. ➤ While most recent guidelines for the prevention of endocarditis have favored treatment of fewer patients, the most recent recommendations for prevention of periprosthetic joint infection have increased the number of patients who would receive antibiotics before a dental procedure. ➤ Antibiotics given before a dental procedure decrease the risk of bacteremia from the oral cavity, but this is of uncertain clinical importance. ➤ The number of patients who would require antibiotics before dental procedures to prevent one periprosthetic joint infection greatly outnumbers the number of patients who would experience an adverse event associated with antibiotics given before a dental procedure.