A multicenter, investigator-blinded, randomized comparison of oral levofloxacin and oral clarithromycin in the treatment of acute bacterial sinusitis

A multicenter, investigator-blinded, randomized, parallel-group study was conducted to compare oral levofloxacin 500 mg once/day for 14 days with clarithromycin 500 mg twice/day for 14 days in the treatment of acute bacterial sinusitis. Of 216 adult outpatients randomized to treatment, 190 were evaluable for efficacy. The primary efficacy measure was clinical response, based on resolution of signs and symptoms 2-5 days after therapy. A secondary efficacy measure was relapse rate 1 month after therapy. Among evaluable patients, clinical success rates (cured or improved) were 96.0% and 93.3% for levofloxacin (L) and clarithromycin (C), respectively (95% CI -9.2%, 3.7%). The confidence interval (CI) for treatment difference (C-L) included zero and its upper limit was less than 15%, indicating that levofloxacin was as effective as clarithromycin. In all, 4.1% of patients receiving levofloxacin and 7.2% receiving clarithromycin had a relapse of symptoms 1 month after therapy (95% CI-12.2%, 3.2%). Long-term success (initial success, absence of relapse at 1 month, no further antibacterial therapy 2-5 days after therapy) was 79.2% in the levofloxacin group and 76.4% in the clarithromycin group (95% CI -14.7%, 9.0%). Based on investigator-assessed treatment-emergent adverse events, overall tolerability of the drugs was similar, except for a higher frequency of taste perversion and diarrhea in the clarithromycin group. Levofloxacin had an advantage over clarithromycin based on two quality-of-life (QOL) parameters: number of times taking other drugs for targeted medical conditions and mean total cost of these drugs. No statistical significance was found in other QOL variables. These findings suggest that the efficacy and tolerability of levofloxacin 500 mg once/day are comparable with those of clarithromycin 500 mg twice/day in the treatment of acute bacterial sinusitis.

14. Effects of an Opt-Out Protocol for Antibiotic De-escalation among Selected Patients with Suspected Sepsis: The DETOURS Trial

Background

Sepsis guidelines recommend daily review to de-escalate or stop antibiotics in appropriate patients. We conducted a randomized controlled trial (NCT03517007) of an opt-out protocol to decrease unnecessary antibiotics in selected patients with suspected sepsis.

Methods

We evaluated non-ICU adults remaining on broad-spectrum antibiotics with negative blood cultures at 48-96 hours at ten U.S. hospitals during September 2018-May 2020. A 23-item safety check excluded patients with ongoing signs of infection, concerning or inadequate microbiologic data, or high-risk conditions (Figure 1). Eligible patients were randomized to the opt-out protocol vs. usual care. The primary outcome was 30-day post-enrollment antibacterial days of therapy (DOT). Clinicians caring for intervention patients were contacted by a pharmacist or physician to encourage antibiotic discontinuation or de-escalation using opt-out language, discuss rationale for continuing antibiotics, working diagnosis, and de-escalation and duration plans. Hurdle models separately compared the odds of antibiotic continuation and DOT distributions among those who continued antibiotics.

Components of the De-Escalating Empiric Therapy: Opting-OUt of Rx in Selected patients with Suspected Sepsis (DETOURS) Trial Protocol

Results

Among 9606 screened, 767 (8%) were enrolled (Figure 2). Common reasons for exclusion were antibiotics given prior to blood culture (35%), positive culture from non-blood sites (26%), and increased oxygen requirement (21%). Intervention patients had 32% lower odds of antibiotic continuation (79% vs. 84%, OR 0.68, 95% confidence interval [0.47, 0.98]). DOT distributions among those who continued antibiotics were similar (ratio of means 1.06 [0.88-1.26], Figure 3). Fewer intervention patients were exposed to extended-spectrum agents (38% vs. 44%). Common reasons for continuing antibiotics were treatment of localized infection (76%) and belief that stopping antibiotics was not safe (31%). Safety outcomes such as mortality, readmission, sepsis relapse, C. difficile, and length of stay did not differ.

DETOURS Trial Flow Diagram

Flow of participants through the DETOURS Trial.

Observed Days of Antibiotic Therapy Among Intervention and Control Subjects in the DETOURS Trial

Post-enrollment days of antibiotic therapy among 767 DETOURS Trial participants in 10 US acute care hospitals within 30 days after enrollment. Dark pink color indicates percent overlap between intervention (purple) and control (light pink) groups.

Conclusion

In this patient-level randomized trial of a stewardship intervention, the opt-out de-escalation protocol targeting selected patients with suspected sepsis resulted in more antibiotic discontinuations but did not affect safety events.

Disclosures

Rebekah W. Moehring, MD, MPH, UpToDate, Inc. (Other Financial or Material Support, Author Royalties) Michael Z. David, MD PhD, GSK (Board Member) Michael Klompas, MD, MPH, UpToDate (Other Financial or Material Support, Chapter Author)

2087. Electronic Capture and Feedback of Standardized Antibiotic Clinical Indications Data Among Community Hospitals

Background

Antibiotic clinical indications allow stewardship programs to assess therapy appropriateness; however, many hospitals that require antibiotic indications upon order entry lack standardized mapping of indications leading to variability in entered values. Electronic capture and feedback of standardized antibiotic clinical indications data may allow hospitals to more effectively compare indication-specific prescribing trends among facilities.

Methods

We collected antibiotic indications from electronic medication orders for 6 DASON hospitals. These indications were mapped to a list of 15 standardized indication categories created by consensus of the DASON stewardship team. To demonstrate the feasibility and utility of standardized clinical indications mapping, we evaluated agents given for the indication C. difficile infection (CDI) in 2018. Differences between the hospitals were compared with highlight the added benefit of standardized indication data in evaluating antibiotic use and adoption of local guidelines.

Results

For 249,916 antibiotic days of therapy (DOT) with an indication available, a total of 125 unique indications were reported. Of note, 3 facilities allowed more than one indication to be entered at prescriber discretion. The distribution of antibiotic DOT mapped to the standardized indication list can be seen in Figure 1. The most common indication was the other category (19.5%). These were primarily other, no additional information (47%) or empiric therapy for an unknown source of infection (17%). Additional indications in the other category included chronic obstructive pulmonary disease exacerbations and sexually transmitted infections (< 5% each). Figure 2 depicts the agents used for CDI indication between facilities. Despite universal adoption of local guidelines where oral vancomycin is the drug of choice for treating CDI, there was variability seen in vancomycin CDI DOT (range: 60 – 80% of CDI DOT).

Conclusion

Stewardship programs can implement standardized antimicrobial indications to facilitate electronic capture, feedback, and comparison and efficiently identify stewardship targets. Additionally, hospitals may use these data to explore the appropriateness of antibiotic use.

Disclosures

All authors: No reported disclosures.

1571. Hospital COVID-19 Burden Impact on Inpatient Antibiotic Use Rates

Background

COVID-19 shifted antibiotic stewardship program resources and changed antibiotic use (AU). Shifts in patient populations with COVID surges, including pauses to surgical procedures, and dynamic practice changes makes temporal associations difficult to interpret. Our analysis aimed to address the impact of COVID on AU after adjusting for other practice shifts.

Methods

We performed a longitudinal analysis of AU data from 30 Southeast US hospitals. Three pandemic phases (1: 3/20–6/20; 2: 7/20–10/20; 3: 11/20–2/21) were compared to baseline (1/2018–1/2020). AU (days of therapy (DOT)/1000 patient days (PD)) was collected for all antimicrobial agents and specific subgroups: broad spectrum (NHSN group for hospital-onset infections), CAP (ceftriaxone, azithromycin, levofloxacin, moxifloxacin, and doxycycline), and antifungal. Monthly COVID burden was defined as all PD attributed to a COVID admission. We fit negative binomial GEE models to AU including phase and interaction terms between COVID burden and phase to test the hypothesis that AU changes during the phases were related to COVID burden. Models included adjustment for Charlson comorbidity, surgical volume, time since 12/2017 and seasonality.

Results

Observed AU rates by subgroup varied over time; peaks were observed for different subgroups during distinct pandemic phases (Figure). Compared to baseline, we observed a significant increase in overall, broad spectrum, and CAP groups during phase 1 (Table). In phase 2, overall and CAP AU was significantly higher than baseline, but in phase 3, AU was similar to baseline. These phase changes were separate from effects of COVID burden, except in phase 1 where we observed significant effects on antifungal (increased) and CAP (decreased) AU (Table).

Conclusion

Changes in hospital AU observed during early phases of the COVID pandemic appeared unrelated to COVID burden and may have been due to indirect pandemic effects (e.g., case mix, healthcare resource shifts). By pandemic phase 3, these disruptive effects were not as apparent, potentially related to shifts in non-COVID patient populations or ASP resources, availability of COVID treatments, or increased learning, diagnostic certainty, and provider comfort with avoiding antibacterials in patients with suspected COVID over time.

Disclosures

Melissa D. Johnson, PharmD, Biomeme: Licensed Transcriptional Signature for Candidemia|Charles River Laboratories: Grant/Research Support|Entasis Therapeutics: Advisor/Consultant|Merck & Co. Inc: Advisor/Consultant|Merck & Co. Inc: Grant/Research Support|Pfizer, Inc.: Advisor/Consultant|Scynexis Inc.: Grant/Research Support|Theratechnologies: Advisor/Consultant Angelina Davis, PharmD, M.S., Merck & Co.: Honoraria Sonali D. Advani, MBBS, MPH, FIDSA, Locus Biosciences: Advisor/Consultant|Locus Biosciences: Honoraria|Sysmex America: Advisor/Consultant Ibukun Kalu, MD, Pfizer, Inc.: Institutional support for clinical trial Rebekah W. Moehring, MD, MPH, FIDSA, FSHEA, UpToDate, Inc.: Author Royalties.

Mal perforans and spina bifida occulta

A 26-year-old man had mal perforans pedis as the principal manifestation of spina bifida occulta with an associated intradural lipoma. Two lumbosacral dimples and a tuft of hair overlying the spina bifida led to the diagnosis. We include a review of the causes of mal perforans and a review of spina bifida occulta and associated abnormalities.

Pathological aspects of the infertile testis

In this review, the pathological findings from testicular biopsies of men suffering from various types of infertility are presented. The causes of male infertility are divided into three major categories: pretesticular, testicular, and post-testicular causes. The pre-testicular causes of infertility may be defined as extra-gonadal endocrine disorders, such as those originating in the hypothalamus, pituitary, or adrenals, which have an adverse effect on spermatogenesis. The testicular causes of infertility are primary defects of the testes. The post-testicular causes of infertility consist primarily of obstructions of the ducts leading away from the testes. Cases in which the spermatozoa are normal in number but greatly impaired in motility, presumably due to faulty maturation or improper preservation of the spermatozoa during their sojourn in the epididymides, or due to biochemical abnormalities of the seminal plasma, are also included in the postesticular category.

Developing work readiness in university graduates: a case study in mapping a university curriculum to work readiness domains in an Australian physiotherapy degree

BACKGROUND

Recent research has identified six domains of work readiness: Practical Wisdom, Interpersonal Capabilities, Personal Attributes, Organisational Acumen, Profession Specific Knowledge and Skills, and Professionally Relevant Experiences.

OBJECTIVE

Using a case study, the aim of this study was to demonstrate the process of curriculum mapping to evaluate the alignment of a university program to the work readiness framework.

METHODS

A retrospective audit of curriculum material for one cohort of Macquarie University's Doctor of Physiotherapy (DPT) was undertaken. Curriculum was categorized as declared, delivered, or assessed, mapped to the six work readiness domains through qualitative content analysis, and then quantitatively scored and expressed as percentages of maximum possible scores per unit, and average units scores per semester.

RESULTS

Mapping curriculum to a six domain work readiness framework revealed declared, delivered, and assessed curriculum within all six work readiness domains, with varying contributions across the degree. Mapping revealed that the Profession Specific Knowledge and Skills domain had the highest coverage of declared (M = 63%, SD = 12), delivered (M = 88%, SD = 11) and assessed (M = 80%, SD = 7) curriculum, highlighting a strength of the program. The Personal Attributes domain had the lowest coverage of declared (M = 5%, SD = 5), delivered (M = 48%, SD = 24) and assessed (M = 29%, SD = 20) curriculum, highlighting opportunities for development.

CONCLUSION

Mapping curriculum to a work readiness framework allows universities to consider alignment, and the strength and opportunities for the improvement of work readiness within its curriculum.

Efficacy and tolerance of adapalene cream 0.1% compared with its cream vehicle for the treatment of acne vulgaris

Adapalene gel 0.1% is approved for use in the treatment of acne vulgaris. A new cream formulation, adapalene cream 0.1%, has been developed. Our objective was to evaluate the efficacy and tolerability of adapalene cream 0.1% in comparison with its cream vehicle, applied once daily for 12 weeks to patients with facial acne vulgaris. We used a 12-week, multicenter, randomized, double-blind, vehicle-controlled, comparative phase 3 study of adapalene cream 0.1% and cream vehicle. The study enrolled 237 patients (125 males and 112 females), aged 12 through 30 years, with mild-to-moderate acne vulgaris. Adapalene cream 0.1% demonstrated superior efficacy compared with its cream vehicle. Significantly lower numbers of total inflammatory and noninflammatory lesion counts were observed at the end of the study period in patients using adapalene cream 0.1% as opposed to those using cream vehicle (P<.05 compared with baseline, for all 3 parameters). Adapalene cream 0.1% caused more cutaneous side effects than the cream vehicle, but these were tolerated in most patients. In summary, the results of this study indicate that adapalene cream 0.1% demonstrates superior efficacy over cream vehicle for the treatment of acne vulgaris. Adapalene cream 0.1% also has excellent tolerability and is associated with a low incidence of cutaneous adverse events.

A combination benzoyl peroxide and clindamycin topical gel compared with benzoyl peroxide, clindamycin phosphate, and vehicle in the treatment of acne vulgaris

A topical gel combining 5% benzoyl peroxide and 1% clindamycin as phosphate was evaluated in a 10-week randomized double-blind trial involving 287 patients with moderate to moderately severe acne. The combination agent demonstrated significantly greater reductions in inflammatory lesions than either of its active constituents (5% benzoyl peroxide and 1% clindamycin) or vehicle when used alone. Significantly greater reductions in comedos and improvements, as measured by both physicians' and patients' global evaluations, were obtained with the combination agent than with clindamycin or vehicle. The reduction in comedos and the global improvements were similar between the combination agent and benzoyl peroxide. The combination agent was well tolerated; the incidence of dry skin was similar to that found with benzoyl peroxide, and other adverse events were similar to that with vehicle. The improved efficacy obtained with combination therapy was accompanied by a safety profile similar to that of either constituent used alone.

Mucha-Habermann's disease in children: treatment with erythromycin

Safe therapeutic measures for Mucha-Habermann's disease in children are lacking. Three patients with the disease were treated with erythromycin for systemic effect. Although the series is small and uncontrolled, this approach seemed effective. An anti-inflammatory mechanism related to inhibition of chemotaxis is speculated.

Health care in Denmark

In Denmark, federal control of medicine began as early as 1890. Last year the American College of Medical Group Administrators studied the evolution of that country's health care system and found that it may well have predictive value for American health care planners.