Improving antibacterial prescribing safety in the management of COPD exacerbations: systematic review of observational and clinical studies on potential drug interactions associated with frequently prescribed antibacterials among COPD patients

Tigecycline Pharmacokinetic and Pharmacodynamic Profile in Patients with Chronic Obstructive Pulmonary Disease Exacerbation

BACKGROUND

We aimed to evaluate the pharmacokinetic profile of tigecycline in plasma and its penetration to sputum in moderately ill patients with an infectious acute exacerbation of chronic obstructive pulmonary disease (COPD).

METHODS

Eleven patients hospitalized with acute respiratory failure due to an acute COPD exacerbation with clinical evidence of an infectious cause received tigecycline 50 mg twice daily after an initial loading dose of 100 mg. Blood and sputum samples were collected at steady state after dose seven.

RESULTS

In plasma, mean C_max pl was 975.95 ± 490.36 ng/mL and mean C_min pl was 214.48 ±140.62 ng/mL. In sputum, mean C_{max sp} was 641.91 ± 253.07 ng/mL and mean C_{min sp} was 308.06 ± 61.7 ng/mL. In plasma, mean AUC _{0-12 pl} was 3765.89 ± 1862.23 ng*h/mL, while in sputum mean AUC _{0-12 sp} was 4023.27 ± 793.37 ng*h/mL. The mean penetration ratio for the 10/11 patients was 1.65 ± 1.35. The mean Free AUC_{0-24 pl}/MIC ratio for Streptococcus pneumoniae and Haemophilus influenzae was 25.10 ± 12.42 and 6.02 ± 2.97, respectively.

CONCLUSIONS

Our findings support the clinical effectiveness of tigecycline against commonly causative bacteria in COPD exacerbations and highlight its sufficient lung penetration in pulmonary infections of moderate severity.

Chronic diseases and variations in rates of antimicrobial use in the community: a population-based analysis of linked administrative data in Quebec, Canada, 2002-2017

BACKGROUND

Chronic diseases may increase risk of infection and complications from infections; fear of these risks may lower clinicians' tolerance threshold for the prescription of antimicrobials, thus increasing the risk of selecting resistant bacteria. We sought to describe rates of antimicrobial use in Quebec and measure the association between chronic diseases and utilization rates.

METHODS

Using the Quebec Integrated Chronic Disease Surveillance System, we analyzed data of people covered by the public drug insurance plan in 2002-2017. Based on delivered prescriptions, we described trends in antimicrobial use in the population, and per category of select chronic diseases (i.e., none, respiratory, cardiovascular, diabetes, mental disorder), according to age group (0-17 yr, 18-64 yr and ≥ 65 yr). We computed ratios of extended-to-narrow-spectrum antimicrobials in 2014-2017. We used robust Poisson regression to quantify the association between chronic diseases and rates of antimicrobial use among children and adults (≥ 18 yr).

RESULTS

Between 2002 and 2017, 4 231 724 prescriptions were received over 6 653 473 individual-years among children; 1 367 492 (20.6%) individual-years had at least 1 chronic disease. Among adults aged 18-64 years, 13 365 577 prescriptions were received over 24 935 592 individual-years; 9 533 493 (38.2%) individual-years had at least 1 chronic disease. Among adults 65 years or older, 11 689 365 prescriptions were received over 15 927 342 individual-years; 12 743 588 (80.0%) individual-years had least 1 chronic disease. Antimicrobial use decreased among children, remained stable among younger adults and increased among older adults. Trends were consistent across chronic disease categories in children and older adults. In 2014-2017, 19.9% of children, 39.1% of younger adults and 79.7% of older adults had at least 1 chronic disease. Claims for extended-spectrum antimicrobials were frequent in all age and chronic disease groups, relative to narrow-spectrum antimicrobials (ratios from 3.1:1 to 14.6:1). Antimicrobial use was higher among people with respiratory diseases (adults: relative rate [RR] 2.09, 95% confidence interval [CI] 2.07-2.10; children: RR 1.62, 95% CI 1.59-1.65), mental health diagnoses (adults: RR 1.48, 95% CI 1.46-1.49; children: RR 1.22, 95% 1.20-1.24), diabetes (adults: RR 1.40, 95% CI 1.28-1.41; children: RR 2.02, 95% CI 1.58-2.57) and cardiovascular diseases (adults: RR 1.31, 95% CI 1.30-1.32), compared with those with none of the studied chronic diseases.

INTERPRETATION

During the study period, large proportions of antimicrobial prescriptions were for people with chronic diseases, across the age spectrum. Interventions to reduce antimicrobial use should be tailored for these populations.

Chronic diseases and compliance with provincial guidelines for outpatient antibiotic prescription in cases of otitis media and respiratory infections: a population-based study of linked data in Quebec, Canada, 2010-2017

BACKGROUND

In Quebec, antibiotic use is higher among outpatients with chronic diseases. We sought to measure compliance with provincial guidelines for the treatment of otitis media and common respiratory infections, and to measure variations in compliance according to the presence of certain chronic diseases.

METHODS

We conducted a population-based study of linked data on antibiotic dispensing covered by the public drug insurance plan between April 2010 and March 2017. We included patients who had consulted a primary care physician within 2 days before being dispensed an antibiotic for an infection targeted by provincial guidelines, including bronchitis in patients with chronic obstructive pulmonary disease, otitis media, pharyngitis, pneumonia and sinusitis. We computed proportions of prescriptions compliant with guidelines (use of recommended antibiotic for children, and use of recommended antibiotic and dosage for adults) by age group (children or adults) and chronic disease (respiratory, cardiovascular, diabetes, mental disorder or none). We measured the impact of chronic diseases on compliance using robust Poisson regression.

RESULTS

We analyzed between 14 677 and 198 902 prescriptions for each infection under study. Compliance was greater than 87% among children, but was lower among children with asthma (proportion ratios between 0.97 and 1.00). In adults, the chosen antibiotic was compliant for at least 73% of prescriptions, except for pharyngitis (≤ 61%). Accounting for dosage lowered compliance to between 31% and 61%. Compliance was lower in the presence of chronic diseases (proportion ratios between 0.94 and 0.98).

INTERPRETATION

It is possible that prescribing noncompliant prescriptions was sometimes appropriate, but the high frequency of noncompliance suggests room for improvement. Given that variations associated with chronic diseases were small, disease-specific guidelines for antibiotic prescriptions are likely to have a limited impact on compliance.

Neuropsychiatric safety of varenicline in the general and COPD population with and without psychiatric disorders: a retrospective cohort study in a real-world setting

OBJECTIVES

To evaluate the real-world association between varenicline and neuropsychiatric adverse events (NPAEs) in general and chronic obstructive pulmonary disease (COPD) population with and without psychiatric disorders compared with nicotine replacement therapy (NRT) to strengthen the knowledge of varenicline safety.

DESIGN

A retrospective cohort study.

SETTING

Prescription database IADB.nl, the Netherlands.

PARTICIPANTS

New users of varenicline or NRT among general (≥18 years) and COPD (≥40 years) population. Psychiatric subcohort was defined as people prescribed psychotropic medications (≥2) within 6 months before the index date.

OUTCOME MEASURES

The incidence of NPAEs including depression, anxiety and insomnia, defined by new or naive prescriptions of related medications in IADB.nl within 24 weeks after the first treatment initiation of varenicline or NRT.

RESULTS

For the general population in non-psychiatric cohort, the incidence of total NPAEs in varenicline (4480) and NRT (1970) groups was 10.5% and 12.6%, respectively (adjusted OR (aOR) 0.85, 95% CI 0.72 to 1.00). For the general population in psychiatric cohort, the incidence of total NPAEs was much higher, 75.3% and 78.5% for varenicline (1427) and NRT (1200) groups, respectively (aOR 0.82, 95% CI 0.68 to 0.99). For the COPD population (1598), there were no differences in the incidence of NPAEs between comparison groups in both the psychiatric cohort (aOR 0.97, 95% CI 0.66 to 1.44) and non-psychiatric cohort (aOR 0.81, 95% CI 0.54 to 1.20). Results from subgroup or sensitivity analyses also did not reveal increased risks of NPAEs but showed decreased risk of some subgroup NPAEs associated with varenicline.

CONCLUSIONS

In contrast to the concerns of a possible increased risk of NPAEs among varenicline users, we found a relative decreased risk of total NPAEs in varenicline users of the general population in psychiatric or non-psychiatric cohorts compared with NRT and no difference for NPAEs between varenicline and NRT users in smaller population with COPD.

Use of Antibiotics in Chronic Obstructive Pulmonary Disease: What is Their Current Role in Older Patients?

Chronic obstructive pulmonary disease (COPD) has considerable morbidity and mortality in the older adult population. The role of antibiotics in the management of acute exacerbations of COPD (AECOPD) is currently evolving. Despite only mild benefits, most patients with AECOPD in ambulatory settings receive antibiotics based on clinical criteria. Utilization of point-of-care C-reactive protein (CRP) has reduced antibiotic prescriptions by 20% without compromising clinical outcomes. A strict protocol allowing antibiotic use only in patients with clinical criteria and CRP ≥ 20 mg/L has the potential to reduce antibiotic prescriptions for AECOPD in ambulatory settings by nearly 50%. Amoxicillin and doxycycline are commonly prescribed for AECOPD based on a favorable benefit-to-risk ratio. Prophylactic antibiotics have also been used in selected patients with severe COPD and frequent exacerbations. The use of continuous or intermittent azithromycin has demonstrated efficacy in reducing the frequency of AECOPD in this population; however, this approach has potential for the development of antibiotic resistance and adverse effects. The use of azithromycin prophylaxis in older patients with frequent AECOPD should be determined on a case-by-case basis after careful review, discussion, and counseling of the potential benefits and risks. The role of continuous doxycycline and pulsed moxifloxacin prophylaxis for frequent AECOPD remains controversial.

Potential drug-drug interactions in ICU patients: a retrospective study

Objectives A "potential drug-drug interaction" (pDDI) is the possibility one drug has to alter the effects of another when both are administered simultaneously. Intensive care unit (ICU) patients are especially prone to these pDDIs. This study aimed to determine the frequency and severity of pDDIs during the hospitalization of patients in the ICU. Methods This study was conducted retrospectively in three hospitals, including both governmental and non-governmental hospitals in Nablus, Palestine, over the course of six months; starting in January 2018 and ending in June 2018. The sample size included 232 ICU patients, and medications prescribed during the hospitalization of these patients were evaluated for pDDIs using the drugs.com application. Results A total of 167 patients (72%) were found to have at least one pDDI, while the total number of pDDIs in the study was 422, resulting in an average of 1.82 pDDIs per patient. Out of the total identified pDDIs, 41 interactions (9.7%) were major interactions, 281 (66.6%) were moderate interactions and 100 (23.7%) were minor interactions. The past medical history of these patients showed that many had hypertension (29%), diabetes mellitus (25%) and ischemic heart disease (10%). A serious combination, enoxaparin and aspirin, was found in six patients. Furthermore, as the number of administered drugs increased, the number of interactions increased as well. Conclusions The pDDIs are common in ICU patients. The most common and clinically most important pDDIs require special attention. Polypharmacy significantly increases the number and level of pDDIs, especially in patients with multiple chronic illnesses. Adequate knowledge regarding the most common pDDIs is necessary to enable healthcare professionals to implement ICU strategies that ensure patient safety.