Background Patients with reported beta lactam antibiotic allergies (BLA) are more likely to receive broad-spectrum antibiotics and experience adverse outcomes. Data describing antibiotic allergies among solid organ transplant (SOT) and hematopoietic cell transplant (HCT) recipients are limited. Methods We reviewed records of adult SOT or allogeneic HCT recipients from 1/1/2013-12/31/2017 to characterize reported antibiotic allergies at time of transplant. Inpatient antibiotic use was examined for 100 days post-transplant. Incidence rate ratios (IRR) comparing antibiotic use in BLA and non-BLA groups were calculated using multivariable negative binomial models for two metrics: days of therapy (DOT)/1000 inpatient days and percentage of antibiotic exposure days. Results Among 2153 SOT (65%) and HCT (35%) recipients, 634 (29%) reported any antibiotic allergy and 347 (16%) reported BLA. Inpatient antibiotics were administered to 2020 (94%) patients during the first 100 days post-transplant; average antibiotic exposure was 41% of inpatient days (Interquartile range (IQR) 16.7%, 62.5%). BLA patients had significantly higher DOT for vancomycin (IRR 1.4; 95% confidence interval (CI) [1.2, 1.7]; p<0.001), clindamycin (IRR 7.6; 95% CI [2.2, 32.4]; p=0.001), aztreonam in HCT (IRR 9.7; 95% CI [3.3, 35.0]; p<0.001), and fluoroquinolones in SOT (IRR 2.9; 95% CI [2.1, 4.0]; p<0.001); these findings were consistent when using percentage of antibiotic exposure days. Conclusions Transplant recipients are frequently exposed to antibiotics and have a high prevalence of reported antibiotic allergies. Reported BLA was associated with greater use of beta lactam antibiotic alternatives. Pre-transplant antibiotic allergy evaluation may optimize antibiotic use in this population.
Background. Outpatient antibiotic prescribing for acute upper respiratory infections (URIs) is a high-priority target for antimicrobial stewardship that has not been described for cancer patients.Methods. We conducted a retrospective cohort study of adult patients at an ambulatory cancer center with URI diagnoses from 1 October 2015 to 30 September 2016. We obtained antimicrobial prescribing, respiratory viral testing, and other clinical data at first encounter for the URI through day 14. We used generalized estimating equations to test associations of baseline factors with antibiotic prescribing.Results. Of 341 charts reviewed, 251 (74%) patients were eligible for analysis. Nearly one-third (32%) of patients were prescribed antibiotics for URIs. Respiratory viruses were detected among 85 (75%) of 113 patients tested. Antibiotic prescribing (P = .001) and viral testing (P < .001) varied by clinical service. Sputum production or chest congestion was associated with higher risk of antibiotic prescribing (relative risk [RR], 2.3; 95% confidence interval [CI], 1.4-3.8; P < .001). Viral testing on day 0 was associated with lower risk of antibiotic prescribing (RR, 0.4; 95% CI 0.2-0.8; P = .01), though collinearity between viral testing and clinical service limited our ability to separate these effects on prescribing.Conclusions. Nearly one-third of hematology-oncology outpatients were prescribed antibiotics for URIs, despite viral etiologies identified among 75% of those tested. Antibiotic prescribing was significantly lower among patients who received an initial respiratory viral test. The role of viral testing in antibiotic prescribing for URIs in outpatient oncology settings merits further study.
Modern clubmosses are a vestige of their gargantuan carboniferous ancestors that dominated the paleoflora flora for millions of years. Yet little is known of the ecophysiology of these plants. The goal of this paper was to examine four temperate lycophyte taxa that are commonly found in northeast US temperate forests. We evaluated the relationship of several functional parameters and found evidence of functional ecological convergence largely based on growth form. Species with substantial belowground biomass investment are consistently more similar across multiple traits than taxa with rhizomes that are largely aboveground. Such differences may help explain how these taxa partition their environment and frequently grow in dense multispecies stands.
Background Inappropriate testing for Clostridioides difficile (C. difficile) leads to overdiagnosis of C. difficile infection (CDI). We determined the effect of a computerized clinical decision support (CCDS) order set on C. difficile PCR test utilization and clinical outcomes. Methods An interrupted time series analysis comparing C. difficile PCR test utilization, hospital-onset CDI rates, and clinical outcomes before and after implementation of a CCDS order set at 2 academic medical centers, University of Washington Medical Center (UWMC) and Harborview Medical Center (HMC). Results Compared with the 20-month pre-intervention period, during the 12-months post-implementation of the CCDS order set, there was an immediate and sustained reduction in C. difficile PCR test utilization rates at both hospitals (HMC: -28.2%, [95%CI -43.0%, -9.4%], p=.005; UWMC: -27.4%, [95%CI, -37.5%, -15.6%], p &.001). There was a significant reduction in rates of C. difficile tests ordered in the setting of laxatives (HMC: -60.8%, [95%CI -74.3%, -40.1%], p &0.001; UWMC: -37.3%, [95% CI, -58.2%, -5.9%], p=.02). The intervention was associated with an increase in the C. difficile test positivity rate at HMC (p =.01). There were no significant differences HO-CDI rates or in the proportion of patients with HO-CDI who developed severe CDI or CDI-associated complications including ICU transfer, extended length of stay, 30-day mortality, and toxic megacolon. Conclusions CCDS tools can improve C. difficile diagnostic test stewardship without causing harm. Additional studies are needed to identify key elements of CCDS tools to further optimize C. difficile testing and assess their effect on adverse clinical outcomes.
We surveyed healthcare professionals at a cancer center regarding their knowledge and perceptions of antibiotic use. Most knew the term “antimicrobial stewardship.” Nurses and other staff were less likely than pharmacists or providers to answer knowledge-based questions correctly. Opportunities exist to improve antibiotic knowledge among cancer center staff.
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