Comparative safety of high-dose versus standard-dose influenza vaccination in patients with end-stage renal disease

Comparative safety of different antibiotic regimens for the treatment of outpatient community-acquired pneumonia among otherwise healthy adults

BACKGROUND

Evidence is limited about the comparative safety of antibiotic regimens for treatment of community-acquired pneumonia (CAP). We compared the risk of adverse drug events (ADEs) associated with antibiotic regimens for CAP treatment among otherwise healthy, non-elderly adults.

METHODS

We conducted an active comparator new-user cohort study (2007-2019) of commercially-insured adults 18-64 years diagnosed with outpatient CAP, evaluated via chest x-ray, and dispensed a same-day CAP-related oral antibiotic regimen. ADE follow-up duration ranged from 2-90 days (e.g., renal failure [14 days]). We estimated risk differences [RD] per 100 treatment episodes and risk ratios using propensity score weighted Kaplan-Meier functions. Ankle/knee sprain and influenza vaccination were considered as negative control outcomes.

RESULTS

Of 145 137 otherwise healthy CAP patients without comorbidities, 52% received narrow-spectrum regimens (44% macrolide, 8% doxycycline) and 48% received broad-spectrum regimens (39% fluoroquinolone, 7% β-lactam, 3% β-lactam + macrolide). Compared with macrolide monotherapy, each broad-spectrum antibiotic regimen was associated with increased risk of several ADEs (eg, β-lactam: nausea/vomiting/abdominal pain [RD per 1000, 3.20; 95% CI, 0.99–5.73]; non–Clostridioides difficile diarrhea [RD per 1000, 4.61; 95% CI, 2.47–6.82]; vulvovaginal candidiasis/vaginitis [RD per 1000, 3.57; 95% CI, 0.87, 6.88]). Narrow-spectrum antibiotic regimens largely conferred similar risk of ADEs. We generally observed similar risks of each negative control outcome, indicating minimal confounding.

CONCLUSIONS

Broad-spectrum antibiotics were associated with increased risk of ADEs among otherwise healthy adults treated for CAP in the outpatient setting. Antimicrobial stewardship is needed to promote judicious use of broad-spectrum antibiotics and ultimately decrease antibiotic-related ADEs.

The efficacy and safety of Niaoduqing granules in the treatment of diabetic kidney disease: a systematic review and meta-analysis

Background: Diabetic nephropathy (DN) is the main cause of chronic kidney disease (CKD) and end-stage renal failure (ESRF), and the control of disease progression and adverse events during treatment needs to be improved. Objective: This study aimed to systematically evaluate the clinical efficacy and safety of Niaoduqing granules (NDQG) in the treatment of diabetic kidney disease (DKD). Method: Randomized controlled trials (RCTs) of NDQG for DKD from Chinese and English databases up to 31 August 2022 were included. The quality of the literature was assessed using the risk of bias tool of the Cochrane Handbook. At a 95% confidence interval (CI), relative risk (RR) and Cohen's d were used for the categorical and continuous variables, respectively, and Stata 16.0 software was used for statistical analysis. A funnel plot and Egger's tests were used to assess publication bias. Result: A total of 4,006 patients were included in 52 RCTs, including 1,987 cases in the control group and 2,019 cases in the treatment group. Compared with conventional treatment (CT), combined NDQG therapy is more effective in improving clinical efficiency [RR = 1.23, 95% confidence interval (1.17, 1.29), p < 0.001, I ² = 53.17%], kidney function (urinary albumin excretion rate [SMD = -0.90, 95% CI (-1.14, -0.66), p < 0.001, I ² = 78.19%], 24hUTP levels [SMD = -0.81, 95% CI (-1.08, -0.55), p < 0.001, I ² = 87.08%], blood urea nitrogen [SMD = -0.54, 95% CI (-0.69, -0.39), p < 0.01, I ² = 77.01%], SCr [SMD = -0.68, 95% CI (-0.90, -0.45), p < 0.001, I ² = 89.97%], CCr [SMD = 0.76, 95% CI (0.10,1.42), p = 0.02, I ² = 95.97%], and Cys-C [SMD = -1.32, 95% CI (-2.25, -0.40), p = 0.01, I ² = 93.44%]), the level of glucose metabolism (fasting blood glucose [SMD = -0.18, 95% CI (-0.38, 0.03), p = 0.10, I ² = 71.18%] and HbA1c [SMD = -0.42, 95% CI (-0.86, -0.02), p = 0.06, I ² = 81.64%]), the level of lipid metabolism (total cholesterol [SMD = -0.70, 95% CI (-1.01, -0.39), p < 0.001, I ² = 86.74%] and triglyceride [SMD = -0.61, 95% CI (-0.87,-0.36), p < 0.001, I ² = 80.64%]), inflammatory factors (Hs-CRP [SMD = -1.00, 95% CI (-1.54, -0.46), p < 0.001, I ² = 86.81%], IL-18 [SMD = -1.25, 95% CI (-1.58, -0.92), p < 0.001, I ² = 0], and TNF-α [SMD = -1.28, 95% CI (-1.64, -0.91), p < 0.001, I ² = 75.73%]), and indicators of oxidative stress (malondialdehyde [SMD = -0.88, 95% CI (-1.22, -0.54), p < 0.001, I ² = 66.01%] and advanced oxidation protein products [SMD = -0.92, 95% CI (-1.85, 0.00), p < 0.001, I ² = 90.68%]). In terms of improving uric acid [SMD = -1.59, 95% CI (-3.45, 0.27), p = 0.09, I ² = 94.67%], 2hPG [SMD = -0.04, 95% CI (-0.61, 0.53), p = 0.89, I ² = 84.33%], HDL-C [SMD = 0.71, 95% CI (0.02, 1.40), p = 0.04, I ² = 87.43%], Hb [SMD = 0.11, 95% CI (-0.10, 0.32), p = 0.32, I ² = 0.00]), and superoxide dismutase [SMD = 1.32, 95% CI (0.44, 2.20), p < 0.001, I ² = 93.48%], the effect is not obvious. Adjuvant treatment with NDQG did not increase the incidence of adverse reactions in the control group [SMD = 0.98, 95% CI (0.71, 1.34), p = 0.89, I ² = 1.59%]. Obvious publication bias was detected by funnel plot and Egger's test. Conclusion: Our meta-analysis showed that adjuvant treatment with NDQG has more advantages than conventional treatment alone in the DKD treatment, which could improve clinical efficiency, kidney function, the level of glucose metabolism, the level of lipid metabolism, inflammatory factors, and oxidative stress indicators. At the same time, it also showed that NDQG are relatively safe. However, more high-quality studies are needed to provide more reliable evidence for clinical use. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022373726, identifier CRD42022373726.

Comparative Safety and Attributable Healthcare Expenditures Following Inappropriate Versus Appropriate Outpatient Antibiotic Prescriptions Among Adults With Upper Respiratory Infections

BACKGROUND

Little is known about the clinical and financial consequences of inappropriate antibiotics. We aimed to estimate the comparative risk of adverse drug events and attributable healthcare expenditures associated with inappropriate versus appropriate antibiotic prescriptions for common respiratory infections.

METHODS

We established a cohort of adults aged 18 to 64 years with an outpatient diagnosis of a bacterial (pharyngitis, sinusitis) or viral respiratory infection (influenza, viral upper respiratory infection, nonsuppurative otitis media, bronchitis) from 1 April 2016 to 30 September 2018 using Merative MarketScan Commercial Database. The exposure was an inappropriate versus appropriate oral antibiotic (ie, non-guideline-recommended vs guideline-recommended antibiotic for bacterial infections; any vs no antibiotic for viral infections). Propensity score-weighted Cox proportional hazards models were used to estimate the association between inappropriate antibiotics and adverse drug events. Two-part models were used to calculate 30-day all-cause attributable healthcare expenditures by infection type.

RESULTS

Among 3 294 598 eligible adults, 43% to 56% received inappropriate antibiotics for bacterial and 7% to 66% for viral infections. Inappropriate antibiotics were associated with increased risk of several adverse drug events, including Clostridioides difficile infection and nausea/vomiting/abdominal pain (hazard ratio, 2.90; 95% confidence interval, 1.31-6.41 and hazard ratio, 1.10; 95% confidence interval, 1.03-1.18, respectively, for pharyngitis). Thirty-day attributable healthcare expenditures were higher among adults who received inappropriate antibiotics for bacterial infections ($18-$67) and variable (-$53 to $49) for viral infections.

CONCLUSIONS

Inappropriate antibiotic prescriptions for respiratory infections were associated with increased risks of patient harm and higher healthcare expenditures, justifying a further call to action to implement outpatient antibiotic stewardship programs.