An ideal treatment for insomnia should help to improve sleep latency and sleep duration with limited awakenings and be without significant adverse effects such as daytime somnolence or decreased alertness. Cognitive behavioral therapy should always be first line treatment. Clinical inertia regarding previous prominent use of benzodiazepines and non-BzRAs will be a significant challenge for patients accustomed to their issuance. The future direction of insomnia treatment should have an emphasis on nonpharmacologic interventions, treating comorbid conditions, and focusing therapy on using benzodiazepines and non-BzRAs as last resorts.

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In the population evaluated, hypotension and trough concentrations were predictors of nephrotoxicity; elevated vancomycin trough concentration had the highest odds of association. These data reinforce the close therapeutic monitoring guidelines for vancomycin trough concentrations, especially when targeting troughs of 15-20 mg/L.

Background Treatment of suspected methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of many antibiotic regimens; however, there is associated toxicity. The Department of Veterans Affairs (VA) hospitals screen each patient for MRSA nares colonization on admission and transfer. The objective was to determine the negative predictive value (NPV) of MRSA screening in the determination of subsequent positive clinical culture for MRSA. High NPVs with MRSA nares screening may be used as a stewardship tool. Methods This was a retrospective cohort study across VA medical centers nationwide from 1 January 2007 to 1 January 2018. Data from patients with MRSA nares screening were obtained from the VA Corporate Data Warehouse. Subsequent clinical cultures within 7 days of the nares swab were evaluated for the presence of MRSA. Sensitivity, specificity, positive predictive values, and NPVs were calculated for the entire cohort as well as subgroups for specific culture sites. Results This cohort yielded 561 325 clinical cultures from a variety of anatomical sites. The sensitivity and specificity for positive MRSA clinical culture were 67.4% and 81.2%, respectively. The NPV of MRSA nares screening for ruling out MRSA infection was 96.5%. The NPV for bloodstream infections was 96.5%, for intraabdominal cultures it was 98.6%, for respiratory cultures it was 96.1%, for wound cultures it was 93.1%, and for cultures from the urinary system it was 99.2%. Conclusion Given the high NPVs, MRSA nares screening may be a powerful stewardship tool for deescalation and avoidance of empirical anti-MRSA therapy.

The Centers for Disease Control and Prevention has promoted the appropriate use of antibiotics since 1995 when it initiated the National Campaign for Appropriate Antibiotic Use in the Community. This study examined upper respiratory tract infections included in the campaign to determine the degree to which antibiotics were appropriately prescribed and subsequent admission rates in a veteran population. This study was a retrospective chart review conducted among outpatients with a diagnosis of a respiratory tract infection, including bronchitis, pharyngitis, sinusitis, or nonspecific upper respiratory tract infection, between January 2009 and December 2011. The study found that 595 (35.8%) patients were treated appropriately, and 1,067 (64.2%) patients received therapy considered inappropriate based on the Get Smart Campaign criteria. Overall the subsequent readmission rate was 1.5%. The majority (77.5%) of patients were prescribed an antibiotic. The most common antibiotics prescribed were azithromycin (39.0%), amoxicillin-clavulanate (13.2%), and moxifloxacin ( T he Centers for Disease Control and Prevention (CDC) haspromoted the appropriate use of antibiotics since 1995 when it initiated the National Campaign for Appropriate Antibiotic Use in the Community (1). In 2003, this program was renamed Get Smart: Know When Antibiotics Work in conjunction with the launch of a national media campaign. The purpose of this campaign was to curb the rise of antimicrobial resistance, which has been deemed a hazard to public health by groups such as the Institute of Medicine (1, 2). Antibiotic prescribing rates for upper respiratory infections (URIs) alarmingly account for three-quarters of all antibiotic prescriptions written by office-based prescribers (1). There are many different symptoms of respiratory illnesses that bring patients to seek medical attention in the outpatient setting. Cough, congestion, fever, chills, nasal discharge, and sputum production are common symptoms of URIs, most of which are self-limiting and viral in origin (3-6). As part of the Get Smart Campaign, the CDC provides diagnostic criteria and prescribing guidelines for URIs (1).This study examines URIs included in the CDC's Get Smart Campaign to determine the degree to which antibiotics were appropriately prescribed in an outpatient veteran population. It also aims to determine symptoms associated with inappropriate treatment and subsequent admission rates. Other published studies were limited by the use of quantities of antibiotics used but were unable to utilize patient specific data, such as diagnoses and patient visits (7). Bronchitis, pharyngitis, sinusitis, and nonspecific upper respiratory infections were included to determine appropriateness of treatment per the Get Smart Campaign recommendations (8-11). MATERIALS AND METHODSStudy design. This study was a retrospective chart review conducted among adult patients who had a diagnosis of a respiratory tract infection.Respiratory tract infections were identified by International Classification...