A Survey of Antimicrobial Stewardship Practices in the Western United States: Successes and Challenges

Antibiotics are one of the most important developments in medicine, and their ability to prevent and control infections has had a major impact in clinical medicine. However, the past three decades have shown an increase in multidrug-resistant organisms (MDROs) in both hospital patients and in the community, decreasing our ability to successfully control infection. Complicating the depletion of effective antimicrobials is the fact that, in the last 10 years, there has also been a decrease in the development of new antibacterial agents. Resistant infections have resulted in increased morbidity and mortality, with a consequential increase in healthcare costs. The utilization of antimicrobial stewardship strategies in hospitals has been shown to decrease antimicrobial use, decrease antimicrobial resistance patterns, decrease the development of secondary infections, reduce adverse medication effects, and consequently decrease healthcare costs. In 2007, the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America published the Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship, encouraging hospitals to implement antimicrobial stewardship programs and presenting a blueprint for their development. After the Guidelines were published, several surveys of current antimicrobial stewardship practices ensued, including ones specific to certain states, ones geared towards the members of certain infectious disease professional societies, and even one attempting to assess antimicrobial stewardship practices nationally. For the most part, these surveys have found fairly widespread implementation of antimicrobial stewardship strategies, even in the absence of formal antimicrobial stewardship programs. However, these surveys have also found that barriers to implementation of stewardship programs are common. Because the Western United States has been relatively under-represented in these surveys, this project aimed to determine to what degree hospitals in western states are engaging in stewardship strategies. Additional aims were to further elucidate the barriers to antimicrobial stewardship, and to identify factors associated with the number of antimicrobial stewardship strategies in use in a facility. A web-based antimicrobial stewardship survey was disseminated via email to pharmacy directors, medical directors, infection control professionals, and other healthcare professionals at general acute care and critical access hospitals in 19 states. Responses (n=105) were summarized using descriptive statistics and univariate analyses of associations between survey respondents and hospital characteristics and the reported usage of the various antimicrobial stewardship strategies. Results demonstrated the widespread use of antimicrobial stewardship strategies, even in spite of simultaneous reports of barriers to the establishment of formal antimicrobial stewardship programs. A multivariate model was developed via multiple linear regression, which identified six predictors of the number of antimicrobial stewardship strategies in use at a hospital. This model can be utilized to guide the further development of antimicrobial stewardship in facilities that are struggling with MDROs

Relationship Between Oral Health and Clinical Osteoporosis Among Hospitalized Patients with and Without Diabetes

Objective: Diabetes mellitus (DM) is associated with poor oral health and osteoporosis (OP). The aim of this study was to assess the relationship between OP, periodontal disease (PD), and other dental and health outcomes in a cohort of hospitalized patients with and without DM. Method: Using a cross-sectional study design, we enrolled consecutive hospitalized patients. We administered a questionnaire to gather demographic information, oral health history, smoking history, and history of OP. We inspected their dentition and reviewed their charts. Data were analyzed using t-tests, chi-square tests, and logistic regression models. Result: Out of 301 patients enrolled, 275 had PD, 102 had DM, and 30 had OP. In univariate analyses, factors associated with OP included older age... (See full abstract in article)

Small Glove Size and Female Gender Are Associated with Greater Reported Difficulty Using Orthopaedic Instruments Among Residents

Introduction:. Smaller hand size has been shown to affect ease of instrument use and surgeon injury rates in multiple surgical subspecialties. Women have a smaller average hand size and are more often affected by this issue than men. The goal of this resident survey was to investigate whether hand size and gender impact self-reported difficulty with instrument use among orthopaedic surgery residents. Methods:. Residents were surveyed about how often they experience difficulty using common orthopaedic instruments. Self-reported difficulty using surgical instruments was compared between residents with small glove (SG, outer ≤7.0) vs. large glove (LG, ≥ 7.5) sizes and between male and female residents. Results:. One hundred forty-five residents (118 males and 27 females) completed the survey for a response rate of 3.7%. The SG group contained 35 residents, with 26 females and 9 males. The LG group contained 110 residents, with 1 female and 109 males. The SG group reported more difficulty than the LG group when using 3/6 instruments: the wire-cutting pliers (71.4% vs. 25.5%), universal T-handle chuck (65.7% vs. 21.4%), and large wire driver (60.0% vs. 24.8%). Female residents reported more difficulty than males for 5/6 instruments. Within the SG group, however, there was no difference in self-reported difficulty between female SG and male SG residents for 4/6 instruments. Conclusions:. The predominantly male LG group reported significantly less difficulty than the more gender mixed though still predominantly female SG group. A subanalysis comparing males and females within the SG group found that there was no difference between SG female and SG male residents for 4/6 of the instruments, suggesting that glove size might impact reported difficulty independently from gender. Although the effect of glove size vs. gender is difficult to differentiate in this study, the high rate of difficulty experienced by male and female residents in the SG group should be considered by residency programs, surgeon educators, and instrument manufacturers as the field of orthopaedic surgery continues to become more diverse. Level of Evidence:. III

Dental loss among ambulatory patients with diabetes

Aims: There is a high prevalence of dental loss among patients with diabetes. Understanding the factors that impact dental loss in this population will aid with developing new strategies for its prevention. Methods: Using a cross-sectional study design, patients with diabetes presenting for routine clinic visit were evaluated with an investigator-administered questionnaire. Data were collected on demographics, dental history, duration, control and complications of diabetes. Results: Among 202 subjects, 100 were female, mean age: 58.9 ± 13.2 years, duration of diabetes: 15.8 ± 11.0 years, and hemoglobin A1c: 7.7 ± 1.6%. Thirty-one patients (15.3%) had lost all their teeth and only 13 patients (6.4%) had all 32 of their natural teeth. Using multiple linear regression, older age (β = −0.146; 95% CI: −0.062 to −0.230), not flossing (β = −3.462; 95% CI: −1.107 to −5.817), and presence of diabetic retinopathy (β = −4.271; 95% CI: −1.307 to −7.236) were significant predictors of dental loss. Conclusions: Dental loss is common in patients with diabetes and is associated with older age, diabetic retinopathy and not flossing. In order to reduce dental loss among patients with diabetes, regular flossing should be emphasized as an important component of dental care

Treatment patterns of galcanezumab versus standard of care preventive migraine medications over 24 months: a US retrospective claims study

To describe long-term (24-month) treatment patterns of patients initiating galcanezumab versus standard-of-care (SOC) preventive migraine treatments including anticonvulsants, beta-blockers, antidepressants, and onabotulinumtoxinA using administrative claims data. This retrospective cohort study, which used Optum de-identified Market Clarity data, included adults with migraine with ≥1 claim for galcanezumab or SOC preventive migraine therapy (September 1, 2018 − March 31, 2020) and continuous database enrollment for 12 months before (baseline) and 24 months after (follow-up) the index date (date of first claim). Baseline patient demographics, clinical characteristics, and treatment patterns were analyzed after 24-month follow-up, including adherence (measured as proportion of days covered [PDC]), persistence, discontinuation (≥60-day gap), restart, and treatment switch. Propensity score matching (1:1) was used to balance the galcanezumab and SOC cohorts. The study included 2307 matched patient pairs with 24-month follow-up. Mean age across cohorts was 44.5 years (females: ∼87%). Patients in the galcanezumab versus SOC cohort demonstrated greater treatment adherence (PDC: 48% vs. 38%), with more patients considered adherent (PDC ≥80%: 26.6% vs. 20.7%) and persistent (322.1 vs. 236.4 days) (all p p p = 0.016). Patients who initiated galcanezumab for migraine prevention had higher treatment adherence and persistence compared with those who initiated SOC medications after 24-month follow-up. Only few patients (3-13%) with migraine, who qualify for preventive treatment, are using them. Conventional preventive treatments have not been developed specifically for migraine treatment, and more than half of the patients stop using them prematurely. Calcitonin gene-related peptide monoclonal antibodies such as galcanezumab, fremanezumab, and erenumab are newer treatments that provide migraine-specific preventive treatment. Prior studies have compared 6- to 12-month migraine medication use by patients starting galcanezumab versus those starting traditional standard of care (SOC) migraine preventive medications. We compared long-term (24-month) migraine medication use in patients starting galcanezumab versus those starting SOC migraine preventive medications to confirm if the results are sustained over a longer period. Over 24 months, patients who used galcanezumab followed the prescribed treatment regimen to a greater extent compared with those who used SOC medications (48% vs. 38%, respectively). Additionally, patients using galcanezumab continued treatment for a longer time compared with those using SOC. Over 24 months, about 85% of patients stopped taking SOC medications, while around 80% of patients stopped taking galcanezumab. Our findings indicate that patients with migraine are more likely to continue using galcanezumab as a preventive treatment for a longer period compared with SOC medications. This study helps identify gaps in the preventive treatment of migraine and provides insights on how they are not being used enough.</p