Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care

Abstract Objective: Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. Design: Retrospective cohort study. Participants: All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019–June 30th, 2020. Methods: Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5–10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. Results: Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non–first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). Conclusions: First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts

On two localized particle filter methods for Lorenz 1963 and 1996 Models

Nonlinear data assimilation methods like particle filters aim to improve the numerical weather prediction (NWP) in non-Gaussian setting. In this manuscript, two recent versions of particle filters, namely the Localized Adaptive Particle Filter (LAPF) and the Localized Mixture Coefficient Particle Filter (LMCPF) are studied in comparison with the Ensemble Kalman Filter when applied to the popular Lorenz 1963 and 1996 models. As these particle filters showed mixed results in the global NWP system at the German meteorological service (DWD), the goal of this work is to show that the LMCPF is able to outperform the LETKF within an experimental design reflecting a standard NWP setup and standard NWP scores. We focus on the root-mean-square-error (RMSE) of truth minus background, respectively, analysis ensemble mean to measure the filter performance. To simulate a standard NWP setup, the methods are studied in the realistic situation where the numerical model is different from the true model or the nature run, respectively. In this study, an improved version of the LMCPF with exact Gaussian mixture particle weights instead of approximate weights is derived and used for the comparison to the Localized Ensemble Transform Kalman Filter (LETKF). The advantages of the LMCPF with exact weights are discovered and the two versions are compared. As in complex NWP systems the individual steps of data assimilation methods are overlaid by a multitude of other processes, the ingredients of the LMCPF are illustrated in a single assimilation step with respect to the three-dimensional Lorenz 1963 model

Particle Filtering and Gaussian Mixtures -- On a Localized Mixture Coefficients Particle Filter (LMCPF) for global NWP

In a global numerical weather prediction (NWP) modeling framework we study the implementation of Gaussian uncertainty of individual particles into the assimilation step of a localized adaptive particle filter (LAPF). We obtain a local representation of the prior distribution as a mixture of basis functions. In the assimilation step, the filter calculates the individual weight coefficients and new particle locations. It can be viewed as a combination of the LAPF and a localized version of a Gaussian mixture filter, i.e., a Localized Mixture Coefficients Particle Filter (LMCPF). Here, we investigate the feasibility of the LMCPF within a global operational framework and evaluate the relationship between prior and posterior distributions and observations. Our simulations are carried out in a standard pre-operational experimental set-up with the full global observing system, 52 km global resolution and $10^6$ model variables. Statistics of particle movement in the assimilation step are calculated. The mixture approach is able to deal with the discrepancy between prior distributions and observation location in a real-world framework and to pull the particles towards the observations in a much better way than the pure LAPF. This shows that using Gaussian uncertainty can be an important tool to improve the analysis and forecast quality in a particle filter framework

Beyond antibiotic prescribing rates: first-line antibiotic selection, prescription duration, and associated factors for respiratory encounters in urgent care

OBJECTIVE: Assess urgent care (UC) clinician prescribing practices and factors associated with first-line antibiotic selection and recommended duration of therapy for sinusitis, acute otitis media (AOM), and pharyngitis. DESIGN: Retrospective cohort study. PARTICIPANTS: All respiratory UC encounters and clinicians in the Intermountain Health (IH) network, July 1st, 2019-June 30th, 2020. METHODS: Descriptive statistics were used to characterize first-line antibiotic selection rates and the duration of antibiotic prescriptions during pharyngitis, sinusitis, and AOM UC encounters. Patient and clinician characteristics were evaluated. System-specific guidelines recommended 5-10 days of penicillin, amoxicillin, or amoxicillin-clavulanate as first-line. Alternative therapies were recommended for penicillin allergy. Generalized estimating equation modeling was used to assess predictors of first-line antibiotic selection, prescription duration, and first-line antibiotic prescriptions for an appropriate duration. RESULTS: Among encounters in which an antibiotic was prescribed, the rate of first-line antibiotic selection was 75%, the recommended duration was 70%, and the rate of first-line antibiotic selection for the recommended duration was 53%. AOM was associated with the highest rate of first-line prescriptions (83%); sinusitis the lowest (69%). Pharyngitis was associated with the highest rate of prescriptions for the recommended duration (91%); AOM the lowest (51%). Penicillin allergy was the strongest predictor of non-first-line selection (OR = 0.02, 95% CI [0.02, 0.02]) and was also associated with extended duration prescriptions (OR = 0.87 [0.80, 0.95]). CONCLUSIONS: First-line antibiotic selection and duration for respiratory UC encounters varied by diagnosis and patient characteristics. These areas can serve as a focus for ongoing stewardship efforts

Immediate Administration of Zoledronic Acid Reduces Aromatase Inhibitor-Associated Bone Loss in Postmenopausal Women With Early Breast Cancer: 12-month analysis of the E-ZO-FAST trial.

BACKGROUND: Letrozole is a proven and effective adjuvant therapy in postmenopausal women with hormone receptor-positive (HR(+)) early breast cancer (EBC). As with other aromatase inhibitors (AIs), long-term letrozole administration is associated with decreased bone mineral density (BMD) and increased fracture risk. This study compared potential bone-protecting effects of immediate vs. delayed administration of zoledronic acid (ZOL) in patients with EBC receiving adjuvant letrozole. PATIENTS AND METHODS: Patients with HR(+) EBC in whom adjuvant letrozole treatment was initiated (2.5 mg/day for 5 years) were randomized to immediate ZOL treatment (immediate ZOL) or delayed ZOL treatment (delayed ZOL) (both at 4 mg every 6 months). Patients in the delayed ZOL group received ZOL only for a BMD T-score that decreased to < -2.0 (lumbar spine [LS] or total hip [TH]) or for fracture. The primary endpoint was percentage change in the LS BMD at month 12. Patients were stratified by established or recent postmenopausal status, baseline T-scores, and adjuvant chemotherapy history. RESULTS: At 12 months, the LS BMD increased in the immediate ZOL group (+2.72%) but decreased in the delayed ZOL group (-2.71%); the absolute difference between groups was significant (5.43%; P < .0001). Across all subgroups, patients receiving immediate ZOL had significantly increased LS and TH BMD vs. those who received delayed ZOL (P < .0001). Differences in fracture incidence or disease recurrence could not be ascertained because of early data cutoff and low incidence of events. Adverse events were generally mild, transient, and consistent with the known safety profiles of both agents. CONCLUSION: Immediate ZOL administration effectively prevented BMD loss and increased BMD in postmenopausal women with HR(+) EBC receiving adjuvant letrozole, regardless of BMD status at baseline