Publications

OBJECTIVE: Few studies have compared the risk of recurrent falls across different types of analgesic use, and with limited adjustment for potential confounders (e.g., pain/depression severity). We assessed analgesic use and the subsequent risk of recurrent falls, among participants with or at risk of knee osteoarthritis (OA).

METHODS: A longitudinal analysis included 4231 participants aged 45-79 years at baseline with 4-year follow-up from the Osteoarthritis Initiative (OAI) cohort study. We grouped participants into six mutually exclusive subgroups based on annually assessed analgesic use in the following hierarchical order of analgesic/central nervous system (CNS) potency: use of (1) opioids, (2) antidepressants, (3) other prescription pain medications, (4) over-the-counter (OTC) pain medications, (5) nutraceuticals, and (6) no analgesics. We used multivariable modified Poisson regression models with a robust error variance to estimate the effect of analgesic use on the risk of recurrent falls (≥2) in the following year, adjusted for demographics and health status/behavior factors.

RESULTS: Opioid use increased from 2.7% at baseline to 3.6% at the 36-month visit (>80% using other analgesics/nutraceuticals), while other prescription pain medication use decreased from 16.7% to 11.9% over this time period. Approximately 15% of participants reported recurrent falls. Compared to those not using analgesics, participants who used opioids and/or antidepressants had a 22-25% increased risk of recurrent falls (opioids: RRadjusted = 1.22, 95% CI = 1.04-1.45; antidepressants: RRadjusted = 1.25, 95% CI = 1.10-1.41).

CONCLUSION: Participants with or at risk of knee OA who used opioids and antidepressants with/without other analgesics/nutraceuticals may have an increased risk of recurrent falls after adjusting for potential confounders. Use of opioids and antidepressants warrants caution.

This study uses Medicaid data to compare prescription opioid use, duration of opioid use, and rates of medication-assisted treatment (buprenorphine, methadone, or naltrexone) among enrollees before and after an overdose event.

To evaluate the utility of ultrasound for detection of the difficult intubation in a preoperative setting. PubMed, Ovid, CINAHL Plus Full Text, and Google Scholar searches using ["difficult airway" OR "difficult intubation" OR "difficult laryngoscopy" OR "difficult ventilation"] AND [ultrasonography OR sonography OR ultrasound] without date limitations. Abstracts without publications, case reports, letters, textbooks, unrelated topics, or foreign language articles were excluded. Ancestry references were included from the reviewed articles. Two reviewers independently performed the query. Each study was reviewed using the STARD checklist to assess blinding, incomplete data reporting, subject attrition, and selection of appropriate statistical tests. Ten studies were included. All used convenience sampling of adult subjects requiring direct laryngoscopy in elective surgical settings. One study is retrospective and nine are prospective observational. Populations included non-obese, obese, pregnant, and thyroidectomy patients in the United States, Turkey, Israel, Canada, Portugal, and China. Airway locations scanned are variable using different protocols and patient positioning. The outcome variable is uniformly the Cormack-Lehane Grade. 114 of the 681 total subjects had difficult laryngoscopies. Significance for sonographic prediction of difficult laryngoscopy occurred at three locations: hyomental distance [52.6 ± 5.8 mm (p < 0.01)], anterior tissue at the hyoid bone [16.9 mm (95 % CI 11.9-21.9) and 15.9 ± 2.7 mm (p < 0.0001)], and the thyrohyoid membrane [34.7 mm (95 % CI 28.8-40.7) and 23.9 ± 3.4 mm (p < 0.0001) and 28.25 ± 4.43 mm (p < 0.001)]. The vocal cords and sternal notch levels have conflicting significance. Limitations include the heterogeneous populations and lack of standard scanning protocols.

An online consultation tool, the Sexually Transmitted Diseases Clinical Consultation Network is a new resource for sexually transmitted disease clinicians and clinic managers. An initial evaluation shows that most requests (29%) were from medical doctors, followed by nurse practitioners (22%). Syphilis queries comprised 39% of consults followed by gonorrhea (12%) and chlamydia (11%).

BACKGROUND: Clostridium difficile (C. difficile) is recognized as a frequent cause of antibiotic-associated diarrhoea and colitis. This review is an update of a previously published Cochrane review.

OBJECTIVES: The aim of this review is to investigate the efficacy and safety of antibiotic therapy for C. difficile-associated diarrhoea (CDAD), or C. difficile infection (CDI), being synonymous terms.

SEARCH METHODS: We searched MEDLINE, EMBASE, CENTRAL and the Cochrane IBD Group Specialized Trials Register from inception to 26 January 2017. We also searched clinicaltrials.gov and clinicaltrialsregister.eu for ongoing trials.

SELECTION CRITERIA: Only randomised controlled trials assessing antibiotic treatment for CDI were included in the review.

DATA COLLECTION AND ANALYSIS: Three authors independently assessed abstracts and full text articles for inclusion and extracted data. The risk of bias was independently rated by two authors. For dichotomous outcomes, we calculated the risk ratio (RR) and corresponding 95% confidence interval (95% CI). We pooled data using a fixed-effect model, except where significant heterogeneity was detected, at which time a random-effects model was used. The following outcomes were sought: sustained symptomatic cure (defined as initial symptomatic response and no recurrence of CDI), sustained bacteriologic cure, adverse reactions to the intervention, death and cost.

MAIN RESULTS: Twenty-two studies (3215 participants) were included. The majority of studies enrolled patients with mild to moderate CDI who could tolerate oral antibiotics. Sixteen of the included studies excluded patients with severe CDI and few patients with severe CDI were included in the other six studies. Twelve different antibiotics were investigated: vancomycin, metronidazole, fusidic acid, nitazoxanide, teicoplanin, rifampin, rifaximin, bacitracin, cadazolid, LFF517, surotomycin and fidaxomicin. Most of the studies were active comparator studies comparing vancomycin with other antibiotics. One small study compared vancomycin to placebo. There were no other studies that compared antibiotic treatment to a placebo or a 'no treatment' control group. The risk of bias was rated as high for 17 of 22 included studies. Vancomycin was found to be more effective than metronidazole for achieving symptomatic cure. Seventy-two per cent (318/444) of metronidazole patients achieved symptomatic cure compared to 79% (339/428) of vancomycin patients (RR 0.90, 95% CI 0.84 to 0.97; moderate quality evidence). Fidaxomicin was found to be more effective than vancomycin for achieving symptomatic cure. Seventy-one per cent (407/572) of fidaxomicin patients achieved symptomatic cure compared to 61% (361/592) of vancomycin patients (RR 1.17, 95% CI 1.04 to 1.31; moderate quality evidence). Teicoplanin may be more effective than vancomycin for achieving a symptomatic cure. Eightly-seven per cent (48/55) of teicoplanin patients achieved symptomatic cure compared to 73% (40/55) of vancomycin patients (RR 1.21, 95% CI 1.00 to 1.46; very low quality evidence). For other comparisons including the one placebo-controlled study the quality of evidence was low or very low due to imprecision and in many cases high risk of bias because of attrition and lack of blinding. One hundred and forty deaths were reported in the studies, all of which were attributed by study authors to the co-morbidities of the participants that lead to acquiring CDI. Although many other adverse events were reported during therapy, these were attributed to the participants' co-morbidities. The only adverse events directly attributed to study medication were rare nausea and transient elevation of liver enzymes. Recent cost data (July 2016) for a 10 day course of treatment shows that metronidazole 500 mg is the least expensive antibiotic with a cost of USD 13 (Health Warehouse). Vancomycin 125 mg costs USD 1779 (Walgreens for 56 tablets) compared to fidaxomicin 200 mg at USD 3453.83 or more (Optimer Pharmaceuticals) and teicoplanin at approximately USD 83.67 (GBP 71.40, British National Formulary).

AUTHORS' CONCLUSIONS: No firm conclusions can be drawn regarding the efficacy of antibiotic treatment in severe CDI as most studies excluded patients with severe disease. The lack of any 'no treatment' control studies does not allow for any conclusions regarding the need for antibiotic treatment in patients with mild CDI beyond withdrawal of the initiating antibiotic. Nonetheless, moderate quality evidence suggests that vancomycin is superior to metronidazole and fidaxomicin is superior to vancomycin. The differences in effectiveness between these antibiotics were not too large and the advantage of metronidazole is its far lower cost compared to the other two antibiotics. The quality of evidence for teicoplanin is very low. Adequately powered studies are needed to determine if teicoplanin performs as well as the other antibiotics. A trial comparing the two cheapest antibiotics, metronidazole and teicoplanin, would be of interest.

Growing antimicrobial resistance and a dwindling antibiotic pipeline have resulted in an emerging postantibiotic era, as patients are now dying from bacterial infections that were once treatable. The fast-paced "Golden Age" of antibiotic development that started in the 1940s has lost momentum; from the 1980s to the early 2000s, there was a 90% decline in the approval of new antibiotics as well as the discovery of few new novel classes. Many companies have shifted away from development due to scientific, regulatory, and economic hurdles that proved antibiotic development to be less attractive compared with more lucrative therapeutic areas. National and global efforts are focusing attention toward potential solutions for reinvigorating the antibiotic pipeline and include "push" incentives such as public-private partnerships and "pull" incentives such as reimbursement reform and market exclusivity. Hybrid models of incentives, global coordination among stakeholders, and the appropriate balance of antibiotic pricing, volume of drug used, and proper antimicrobial stewardship are key to maximizing efforts toward drug development to ensure access to patients in need of these therapies.

Improving the use of antibiotics across the continuum of care is a national priority. Data outlining the misuse of antibiotics in the outpatient setting justify the expansion of antibiotic stewardship programs (ASPs) into this health care setting; however, best practices for outpatient antibiotic stewardship (AS) are not yet defined. In a companion article, we focused on recommendations to overcome challenges related to the implementation of an outpatient ASP (e.g., building the AS team and defining program metrics). In this document, we outline AS interventions that have demonstrated success and highlight opportunities to enhance AS in the outpatient arena. This article summarizes examples of point-of-care testing, policies and interventions, and education strategies to improve antibiotic use that can be used in the outpatient setting.

OBJECTIVES: To address the public health threat of antibiotic resistance, there has been an enhanced call for antibiotic stewardship programs throughout the health care continuum.

SUMMARY: While antibiotic stewardship programs have been well described in the inpatient setting, data on effectiveness and guidance on implementing outpatient programs is scarce. Establishing stewardship practices in the outpatient setting is necessary because more than 60% of human antibiotic use occurs in this setting.

CONCLUSION: In this article, we highlight the importance and need for stewardship in the outpatient setting, discuss strategies for the development of stewardship teams, and discuss potential metrics that can be used to assess effectiveness of antibiotic stewardship interventions.

STUDY DESIGN: Retrospective cohort studyObjectives:To identify independent risk factors associated with community-associated multidrug-resistant Psedomonas aeruginosa (MDRPA) in a population of veterans with spinal cord injury and disorders (SCI/D).

SETTING: A total of 127 Veterans Affairs healthcare facilities.

METHODS: Laboratory results from 1 January 2012 to 31 December 2013 were collected, and MDRPA cultures were compared with non-MDRPA cultures.

RESULTS: One thousand four hundred forty-one cultures were collected from Veterans with SCI/D, including 227 cultures with MDRPA isolates. Characteristics associated with an increased odds of MDRPA include age 50-64 (adjusted odds ratio (aOR)=1.80, 95% confidence interval (CI)=1.13-2.87), MDRPA culture in the past 365 days (aOR=9.12, 95% CI=5.88-14.15) and carbapenem exposure in the past 90 days (aOR=2.56, 95% CI=1.35-4.87). In contrast, paraplegia was associated with a 53% decreased odds of MDRPA compared with those with tetraplegia (aOR=0.47, 95% CI=0.32-0.69).

CONCLUSIONS: Risk factors for community-associated MDRPA include prior history of MDRPA and exposure to carbapenems. Awareness of these factors is important for targeted prevention and treatment of MDRPA in patients with SCI/D.