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We analyzed antibiotic use data from 29 southeastern US hospitals over a 5-year period to determine changes in antibiotic use after the fluoroquinolone US Food and Drug Administration (FDA) advisory update in 2016. Fluoroquinolone use declined both before and after the FDA announcement, and the use of select, alternative antibiotics increased after the announcement.
Fluoroquinolones are among the 4 most commonly prescribed antibiotic classes.1,2 Postmarketing reports of serious adverse events linked to fluoroquinolones include tendonitis, neuropathy, hypoglycemia, psychiatric side effects, and possible aortic vessel rupture, leading to safety label changes in July 2008 and August 2013.3 In July 2016, the US Food and Drug Administration (FDA) strengthened the “black box” warning following an initial safety announcement in May 2016, recommending avoidance of fluoroquinolones for uncomplicated infections such as acute exacerbation of chronic bronchitis, uncomplicated urinary tract infections, and acute bacterial sinusitis.4 Concerns over safety and the association with Clostridiodes difficile infection have led inpatient antimicrobial stewardship programs (ASPs) to develop initiatives to promote avoidance of quinolones. The objective of this study was to quantify the effect of the 2016 FDA “black box” update on inpatient antibiotic use among a cohort of southeastern US hospitals.
The purpose of this study was to quantify the effect of multidrug-resistant (MDR) gram-negative bacteria and methicillin-resistant Staphylococcus aureus (MRSA) healthcare-associated infections (HAIs) on mortality following infection, regardless of patient location.
We conducted a retrospective cohort study of patients with an inpatient admission in the US Department of Veterans Affairs (VA) system between October 1, 2007, and November 30, 2010. We constructed multivariate log-binomial regressions to assess the impact of a positive culture on mortality in the 30- and 90-day periods following the first positive culture, using a propensity-score–matched subsample.
Patients identified with positive cultures due to MDR Acinetobacter (n=218), MDR Pseudomonas aeruginosa (n=1,026), and MDR Enterobacteriaceae (n=3,498) were propensity-score matched to 14,591 patients without positive cultures due to these organisms. In addition, 3,471 patients with positive cultures due to MRSA were propensity-score matched to 12,499 patients without positive MRSA cultures. Multidrug-resistant gram-negative bacteria were associated with a significantly elevated risk of mortality both for invasive (RR, 2.32; 95% CI, 1.85–2.92) and noninvasive cultures (RR, 1.33; 95% CI, 1.22–1.44) during the 30-day period. Similarly, patients with MRSA HAIs (RR, 2.77; 95% CI, 2.39–3.21) and colonizations (RR, 1.32; 95% CI, 1.22–1.50) had an increased risk of death at 30 days.
We found that HAIs due to gram-negative bacteria and MRSA conferred significantly elevated 30- and 90-day risks of mortality. This finding held true both for invasive cultures, which are likely to be true infections, and noninvasive infections, which are possibly colonizations.
Age-related cognitive decline is common and well-documented. Cognitive speed of processing training (SOPT) has been shown to improve trained abilities (Useful Field of View; UFOV), but transfer to individual non-trained cognitive outcomes or neuropsychological composites is sparse. We examine the effects of SOPT on a composite of six equally weighted tests – UFOV, Trail-making A and B, Symbol Digit Modality, Controlled Oral Word Association, Stroop Color and Word, and Digit Vigilance.
681 patients were randomized separately within two age-bands (50–64, ≥ 65) to three SOPT groups (10 initial hours on-site, 10 initial hours on-site plus 4 hours of boosters, or 10 initial hours at-home) or an attention-control group (10 initial hours on-site of crossword puzzles). At one-year, 587 patients (86.2%) had complete data. A repeated measures linear mixed model was used.
Factor analysis revealed a simple unidimensional structure with Cronbach's α of 0.82. The time effect was statistically significant (p < 0.001; ηp2 = 0.246), but the time by treatment group (p = 0.331), time by age-band (p = 0.463), and time by treatment group by age-band (p = 0.564) effects were not.
Compared to the attention-control group who played a computerized crossword puzzle game, assignment to 10–14 hours of SOPT did not significantly improve a composite measure of cognitive abilities.
Standard estimates of the impact of Clostridium difficile infections (CDI) on inpatient lengths of stay (LOS) may overstate inpatient care costs attributable to CDI. In this study, we used multistate modeling (MSM) of CDI timing to reduce bias in estimates of excess LOS.
A retrospective cohort study of all hospitalizations at any of 120 acute care facilities within the US Department of Veterans Affairs (VA) between 2005 and 2012 was conducted. We estimated the excess LOS attributable to CDI using an MSM to address time-dependent bias. Bootstrapping was used to generate 95% confidence intervals (CI). These estimates were compared to unadjusted differences in mean LOS for hospitalizations with and without CDI.
During the study period, there were 3.96 million hospitalizations and 43,540 CDIs. A comparison of unadjusted means suggested an excess LOS of 14.0 days (19.4 vs 5.4 days). In contrast, the MSM estimated an attributable LOS of only 2.27 days (95% CI, 2.14–2.40). The excess LOS for mild-to-moderate CDI was 0.75 days (95% CI, 0.59–0.89), and for severe CDI, it was 4.11 days (95% CI, 3.90–4.32). Substantial variation across the Veteran Integrated Services Networks (VISN) was observed.
CDI significantly contributes to LOS, but the magnitude of its estimated impact is smaller when methods are used that account for the time-varying nature of infection. The greatest impact on LOS occurred among patients with severe CDI. Significant geographic variability was observed. MSM is a useful tool for obtaining more accurate estimates of the inpatient care costs of CDI.
Infect. Control Hosp. Epidemiol. 2015;36(9):1024–1030
The straw itch mite, Pyemotes tritici Lagrèze-Fossat and Montané (Acari: Pyemotidae), was discovered parasitising the goldspotted oak borer, Agrilus auroguttatus Schaeffer (Coleoptera: Buprestidae), an invasive exotic species to California, United States of America, and the Mexican goldspotted oak borer, Agrilus coxalis Waterhouse (Coleoptera: Buprestidae), during surveys for natural enemies for a classical biological control programme for A. auroguttatus. Pyemotes tritici caused low levels of mortality to each species of flatheaded borer, but it will likely not be a good candidate for a biological control programme because it is a generalist parasitoid with deleterious human health effects.
The National Afterschool Association (NAA) standards specify the role of summer day camps (SDC) in promoting healthy nutrition habits of the children attending, identifying foods and beverages to be provided to children and staff roles in promoting good nutrition habits. However, many SDC do not provide meals. Currently, national guidelines specifying what children are allowed to bring to such settings do not exist, nor is there a solid understanding of the current landscape surrounding healthy eating within SDC.
A cross-sectional study design using validated measures with multiple observations was used to determine the types of foods and beverages brought to SDC programmes.
Four large-scale, community-based SDC participated in the study during summer 2011.
The types of foods and beverages brought by children (n 766) and staff (n 87), as well as any instances of staff promoting healthy eating behaviours, were examined via direct observation over 27 d. Additionally, the extent to which current foods and beverages at SDC complied with NAA standards was evaluated.
Less than half of the children brought water, 47 % brought non-100 % juices, 4 % brought soda, 4 % brought a vegetable and 20 % brought fruit. Staff foods and beverages modelled similar patterns. Promotion of healthy eating by staff was observed <1 % of the time.
Findings suggest that foods and beverages brought to SDC by children and staff do not support nutrition standards and staff do not regularly promote healthy eating habits. To assist, professional development, parent education and organizational policies are needed.
Second-generation antipsychotics have been thought to cause fewer
extrapyramidal side-effects (EPS) than first-generation antipsychotics,
but recent pragmatic trials have indicated equivalence.
To determine whether second-generation antipsychotics had better outcomes
in terms of EPS than first-generation drugs.
We conducted an intention-to-treat, secondary analysis of data from an
earlier randomised controlled trial (n = 227). A
clinically significant difference was defined as double or half the
symptoms in groups prescribed first- v.
second-generation antipsychotics, represented by odds ratios greater than
2.0 (indicating advantage for first-generation drugs) or less than 0.5
(indicating advantage for the newer drugs). We also examined EPS in terms
of symptoms emergent at 12 weeks and 52 weeks, and symptoms that had
resolved at these time points.
At baseline those randomised to the first-generation antipsychotic group
(n = 118) had similar EPS to the second-generation
group (n = 109). Indications of resolved Parkinsonism
(OR = 0.5) and akathisia (OR = 0.4) and increased tardive dyskinesia (OR
= 2.2) in the second-generation drug group at 12 weeks were not
statistically significant and the effects were not present by 52 weeks.
Patients in the second-generation group were dramatically (30-fold) less
likely to be prescribed adjunctive anticholinergic medication, despite
equivalence in terms of EPS.
The expected improvement in EPS profiles for participants randomised to
second-generation drugs was not found; the prognosis over 1 year of those
in the first-generation arm was no worse in these terms. The place of
careful prescription of first-generation drugs in contemporary practice
remains to be defined, potentially improving clinical effectiveness and
avoiding life-shortening metabolic disturbances in some patients
currently treated with the narrow range of second-generation
antipsychotics used in routine practice. This has educational
implications because a generation of psychiatrists now has little or no
experience with first-generation antipsychotic prescription.