A 2-Year Pragmatic Trial of Antibiotic Stewardship in 27 Community Nursing Homes

OBJECTIVES: To determine if antibiotic prescribing in community nursing homes (NHs) can be reduced by a multicomponent antibiotic stewardship intervention implemented by medical providers and nursing staff and whether implementation is more effective if performed by a NH chain or a medical provider group. DESIGN: Two-year quality improvement pragmatic implementation trial with two arms (NH chain and medical provider group). SETTING: A total of 27 community NHs in North Carolina that are typical of NHs statewide, conducted before announcement of the US Centers for Medicare and Medicaid Services antibiotic stewardship mandate. PARTICIPANTS: Nursing staff and medical care providers in the participating NHs. INTERVENTION: Standardized antibiotic stewardship quality improvement program, including training modules for nurses and medical providers, posters, algorithms, communication guidelines, quarterly information briefs, an annual quality improvement report, an informational brochure for residents and families, and free continuing education credit. MEASUREMENTS: Antibiotic prescribing rates per 1000 resident days overall and by infection type; rate of urine test ordering; and incidence of Clostridium difficile and methicillin-resistant Staphylococcus aureus (MRSA) infections. RESULTS: Systemic antibiotic prescription rates decreased from baseline by 18% at 12 months (incident rate ratio [IRR] = 0.82; 95% confidence interval [CI] = 0.69-0.98) and 23% at 24 months (IRR = 0.77; 95% CI = 0.65-0.90). A 10% increase in the proportion of residents with the medical director as primary physician was associated with a 4% reduction in prescribing (IRR = 0.96; 95% CI = 0.92-0.99). Incidence of C. difficile and MRSA infections, hospitalizations, and hospital readmissions did not change significantly. No adverse events from antibiotic nonprescription were reported. Estimated 2-year implementation costs per NH, exclusive of medical provider time, ranged from $354 to$3653. CONCLUSIONS: Antibiotic stewardship programs can be successfully disseminated in community NHs through either NH administration or medical provider groups and can achieve significant reductions in antibiotic use for at least 2 years. Medical director involvement is an important element of program success

On The Propagation And Modulation Of Electrostatic Solitary Waves Observed Near The Magnetopause On Cluster

International audienceWe present the results of a study of Electrostatic Solitary Waves (ESWs) in which propagation of a series of noncyclical ESWs is observed from one Cluster spacecraft to another over distances as great as tens of km and time lags as great as a few tens of ms. This propagation study was conducted for locations near the magnetopause on the magnetosheath side. Propagation was found primarily toward the earth with speeds on the order of 1500 to 2400 km/s. The sizes of the ESWs obtained from these velocities were on the order of 1 km along the magnetic field direction and several tens of km perpendicular. These results are consistent with measurements on single spacecraft in which the ESW propagation is observed with time lags of only ∼0.1 ms. Our results thus show the stability of ESWs over time periods much greater than their own characteristic pulse durations of a few 100s of microseconds. We present also the results of a study of ESW modulation at the magnetopause on the earthward side. We found that ESWs were modulated at ∼1.3 Hz, consistent with a Pc1 wave which was observed concurrently. During this time, tens of eV electron beams are present. We propose a Buneman type instability in which the E'''' component of the Pc1 waves provides a mechanism for accelerating electrons, resulting in the generation of the ESWs modulated at the Pc1 frequency

Seed ecology of the invasive tropical tree Parkinsonia aculeata

Parkinsonia aculeata is an invasive tree native to tropical America, but introduced to Australia. Propagation and stand regeneration is mainly by seed. To gain baseline knowledge for management decisions, seed bank dynamics were monitored for two months during the fruit dispersal period at a coastal wetland in Costa Rica (native habitat), and at a coastal wetland and two semi-arid rangeland sites in Northern Queensland, Australia (introduced habitats). Seed bank densities underneath dense, uniform Parkinsonia stands were found to be lowest in the Australian wetland but highest in the Costa Rican wetland. Post-dispersal seed losses were highest in the Australian wetland, primarily due to seed germination and/or death. At the other sites, seed losses were minor during the study period, and predation was the most important cause of losses. At the two rangeland sites bruchid beetles accounted for more than 95% of the seed losses by predation. Total predation was lowest in the Costa Rican wetland. In order to test for intrinsic differences of seed characteristics, germination trials were conducted using both canopy seeds and seeds from the soil seed bank. Dormancy release and germination rate were studied under four temperature treatments. In all populations, dormancy release increased with increasing temperature, but averaged responses were significantly different between Costa Rican and Australian seed populations, and between seeds collected from the soil and from trees. Germination rate of scarified seeds was fastest at 35°C in all tested seed populations. While high seed germination levels seem to explain low seed bank densities in the Australian wetland, the large seed banks at the rangeland sites reflect the lower incidence of favourable conditions for germination. In the Australian wetland biocontrol with bruchids is unlikely to be successful, while control by conventional methods, such as killing stands by basal bark spraying, seems feasible, due to a lower long-term risk of re-infestation from the soil seed bank. At the rangeland sites conventional control will be difficult and costly. Parkinsonia stands may be better left to their own, while bruchid populations are monitored and management efforts are concentrated on preventing further invasion