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Mulugeta SG, MacDonald NC, El-Khoury CJ, Davis SL, Kenney RM. Impact of a Standardized, Pharmacist-Initiated "Test-Claim" Workflow for Anticipating Barriers to Accessing Discharge Antimicrobials. J Pharm Technol 2023; 39:218-223. [PMID: 37745731 PMCID: PMC10515972 DOI: 10.1177/87551225231196047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/26/2023] Open
Abstract
Background: Inability to access and afford discharge oral antimicrobials may delay discharges or result in therapeutic failure. "Test-claims" have the potential to identify such barriers. Objective: This study evaluated discharge antimicrobial access and patient outcomes after implementation of a standardized, inpatient pharmacist-initiated antimicrobial discharge medication cost inquiry (aDMCI) process. Methods: This was an Institutional Review Board (IRB)-approved, pilot retrospective cohort study that included adults admitted for ≥72 hours from November 1, 2018, to February 28, 2019, and discharged on oral antimicrobials. Patients with a cost inquiry (aDMCI group) were compared with those without (standard-of-care, SOC, group). Primary endpoint was discharge delay. Secondary endpoints included percentage of patients discharged on suboptimal antimicrobials and medication errors from aDMCI. Results: 84 patients were included: 43 in SOC and 41 in aDMCI. Seventy-five antimicrobial cost inquiries were evaluated among 41 patients. There were no discharge delays or medication errors associated with the standardized "test-claim" (aDMCI) workflow. Patients in the SOC group had a greater Charlson Comorbidity Index (4 [2-6] vs 2 [1-4], P =0.004), were more likely to be immunosuppressed (24, 56% vs 12, 29%; P =0.014), and had longer hospitalization (8 [5-15] vs 6 [5-9] days, P =0.026). Primary access barriers were prior-authorization (8, 11%) and associated with linezolid and moxifloxacin cost inquiries. Most aDMCIs results were available in <24 hours (66, 88%). Conclusions: The aDMCI process is safe and offers an actionable transition of care tool that can identify barriers to accessing discharge medications while insulating patients from surprise out-of-pocket cost.
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Affiliation(s)
| | | | | | - Susan L. Davis
- Pharmacy Division, Henry Ford Health, Detroit, MI, USA
- Wayne State University, Detroit, MI, USA
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2
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Trends in facility-level rates of Clostridioides difficile infections in US hospitals, 2019-2020. Infect Control Hosp Epidemiol 2023; 44:238-245. [PMID: 35586888 DOI: 10.1017/ice.2022.69] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES The coronavirus disease 2019 pandemic caused substantial changes to healthcare delivery and antibiotic prescribing beginning in March 2020. To assess pandemic impact on Clostridioides difficile infection (CDI) rates, we described patients and trends in facility-level incidence, testing rates, and percent positivity during 2019-2020 in a large cohort of US hospitals. METHODS We estimated and compared rates of community-onset CDI (CO-CDI) per 10,000 discharges, hospital-onset CDI (HO-CDI) per 10,000 patient days, and C. difficile testing rates per 10,000 discharges in 2019 and 2020. We calculated percent positivity as the number of inpatients diagnosed with CDI over the total number of discharges with a test for C. difficile. We used an interrupted time series (ITS) design with negative binomial and logistic regression models to describe level and trend changes in rates and percent positivity before and after March 2020. RESULTS In pairwise comparisons, overall CO-CDI rates decreased from 20.0 to 15.8 between 2019 and 2020 (P < .0001). HO-CDI rates did not change. Using ITS, we detected decreasing monthly trends in CO-CDI (-1% per month, P = .0036) and HO-CDI incidence (-1% per month, P < .0001) during the baseline period, prior to the COVID-19 pandemic declaration. We detected no change in monthly trends for CO-CDI or HO-CDI incidence or percent positivity after March 2020 compared with the baseline period. CONCLUSIONS While there was a slight downward trajectory in CDI trends prior to March 2020, no significant change in CDI trends occurred during the COVID-19 pandemic despite changes in infection control practices, antibiotic use, and healthcare delivery.
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Preferences of Healthcare Professionals on 3D-Printed Tablets: A Pilot Study. Pharmaceutics 2022; 14:pharmaceutics14071521. [PMID: 35890417 PMCID: PMC9319202 DOI: 10.3390/pharmaceutics14071521] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/15/2022] [Accepted: 07/20/2022] [Indexed: 02/06/2023] Open
Abstract
Highlights Abstract An inaugural study was performed to understand the perceptions of healthcare professionals toward the potential benefits of 3D printing in Singapore. This study sought to increase awareness of 3D printing applications for viable clinical applications and to elucidate the current gaps in therapy where 3D printing could play a role. A common example would be the use of 3D printing to manufacture polypills, thereby reducing the daily pill burden of patients and possibly improving medication adherence. A qualitative descriptive survey with a single-centered cross-sectional design was performed at Tan Tock Seng Hospital, a tertiary referral hospital with 1700 beds. This study had a total of 55 respondents comprising doctors and pharmacists. Most of the respondents viewed the 3D printing of oral dosage forms favorably and agreed about the potential advantages this technology could offer. More than 60% of the respondents were also willing to prescribe 3D printed tablets to patients. Respondents’ concerns were grouped into three main categories: formulation considerations, manufacturing processes, and administrative issues. Viewed in its entirety, this study provides a valuable starting point for understanding the perceptions of healthcare professionals in adopting 3D printing technology.
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Oral Vancomycin Prophylaxis for Primary and Secondary Prevention of Clostridioides difficile Infection in Patients Treated with Systemic Antibiotic Therapy: A Systematic Review, Meta-Analysis and Trial Sequential Analysis. Antibiotics (Basel) 2022; 11:antibiotics11020183. [PMID: 35203786 PMCID: PMC8868369 DOI: 10.3390/antibiotics11020183] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Revised: 01/26/2022] [Accepted: 01/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background: Clostridioides difficile infection (CDI) is associated with substantial morbidity and mortality as well as high propensity of recurrence. Systemic antibiotic therapy (SAT) represents the top inciting factor of CDI, both primary and recurrent (rCDI). Among the many strategies aimed to prevent CDI in high-risk subjects undergoing SAT, oral vancomycin prophylaxis (OVP) appears promising under a cost-effectiveness perspective. Methods: A systematic review with meta-analysis and trial sequential analysis (TSA) of studies assessing the efficacy and the safety of OVP to prevent primary CDI and rCDI in persons undergoing SAT was carried out. PubMed and EMBASE were searched until 30 September 2021. The protocol was pre-registered on PROSPERO (CRD42019145543). Results: Eleven studies met the inclusion criteria, only one being a randomized controlled trial (RCT). Overall, 929 subjects received OVP and 2011 represented the comparator group (no active prophylaxis). OVP exerted a strong protective effect for CDI occurrence: odds ratio 0.14, 95% confidence interval 0.04–0.38. Moderate heterogeneity was observed: I2 54%. This effect was confirmed throughout several subgroup analyses, including prevention of primary CDI versus rCDI. TSA results pointed at the conclusive nature of the evidence. Results were robust to a variety of sensitivity and quantitative bias analyses, although the underlying evidence was deemed as low quality. No differences between the two groups were highlighted regarding the onset of vancomycin-resistant Enterococcus infections. Conclusions: OVP appears to be an efficacious option for prevention of CDI in high-risk subjects undergoing SAT. Nevertheless, additional data from RCTs are needed to establish OVP as good clinical practice and define optimal dosage and duration.
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Fang N, Ha D, Dong K, Leung T, Lee S, Holubar M, Meng L. Successful fidaxomicin hospital discharges of adult patients with Clostridioides difficile infections post 2021 guidelines - are economic barriers finally coming down? Clin Infect Dis 2021; 75:519-521. [PMID: 34971358 DOI: 10.1093/cid/ciab1061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Indexed: 11/14/2022] Open
Abstract
We reviewed C.difficile positive patients discharged on fidaxomicin after local adoption of 2021C.difficile infection (CDI) guidelines. From June 14 - Oct 3, 2021, 80% (12/15) had copayments $0-$35, and 27% (4/15) required prior authorization. The 30-day CDI recurrence was 7%.
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Affiliation(s)
- Noah Fang
- Department of Pharmacy, Stanford Health Care, Stanford, CA, USA
| | - David Ha
- Department of Quality, Stanford Health Care, Stanford, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, CA, USA
| | - Kimberly Dong
- Department of Pharmacy, Stanford Health Care, Stanford, CA, USA
| | - Thomas Leung
- Department of Pharmacy, Stanford Health Care, Stanford, CA, USA
| | - Sydney Lee
- Department of Pharmacy, Stanford Health Care, Stanford, CA, USA
| | - Marisa Holubar
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, CA, USA
| | - Lina Meng
- Department of Quality, Stanford Health Care, Stanford, CA, USA.,Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.,Stanford Antimicrobial Safety and Sustainability Program, Stanford, CA, USA
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6
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Buehrle D, Clancy CJ. Medicare Prescription Plans Limit Access to Recommended Drugs for Clostridioides difficile Infection. Clin Infect Dis 2021; 74:2227-2229. [PMID: 34626478 DOI: 10.1093/cid/ciab898] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Indexed: 11/15/2022] Open
Abstract
We analyzed June 2021 Medicare Advantage/Part D enrollment and formulary data. Oral vancomycin and fidaxomicin, frontline Clostridioides difficile treatments, were on formulary for 100% (42,314,676/42,314,676) and 84.1% (35,598,385/42,314,676) of enrollees, respectively. However, they were broadly accessible (formulary, unrestricted, Tier 1 or 2) to only 14.4% (6,104,348/42,314,676) and 1.1% (483,004/42,314,676), respectively.
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Affiliation(s)
| | - Cornelius J Clancy
- VA Pittsburgh Healthcare System, Pittsburgh, PA.,University of Pittsburgh, Department of Medicine
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7
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Clancy CJ, Buehrle D, Vu M, Wagener MM, Nguyen MH. Impact of Revised Infectious Diseases Society of America and Society for Healthcare Epidemiology of America Clinical Practice Guidelines on the Treatment of Clostridium difficile Infections in the United States. Clin Infect Dis 2021; 72:1944-1949. [PMID: 32343766 DOI: 10.1093/cid/ciaa484] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2020] [Accepted: 04/23/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Our objective was to determine if oral vancomycin, fidaxomicin, and oral metronidazole use in the United States changed after publication of revised clinical practice guidelines for Clostridium difficile infection (CDI) in February 2018. METHODS We obtained US antibiotic prescription data (IQVIA) from 2006-August 2019 and used guideline-recommended dosing regimens to estimate monthly numbers of 10-day treatment courses of vancomycin, fidaxomicin and metronidazole. Interrupted time-series analyses were performed, adjusted by month. We compared linear trends for monthly numbers of treatment courses in different time periods. RESULTS Cumulative treatment courses of oral vancomycin and fidaxomicin increased by 54% (n = 226 166) and 48% (n = 18 518), respectively, in 18 months following guidelines compared with 18 months before; those of oral metronidazole decreased by 3% (n = 238 372). Monthly vancomycin and fidaxomicin use significantly increased throughout the period following revised guidelines (P < .0001 and P = .0002, respectively), whereas that of metronidazole decreased significantly (P < .0001). Monthly vancomycin use increased and metronidazole use decreased to a significantly greater extent after publication of revised guidelines than after publication of clinical trials establishing superiority of vancomycin over metronidazole (P < .0001). CONCLUSIONS Revised practice guidelines have had a significant impact on CDI treatment in the US. Clinical trial data used for the revised guidelines were available since 2007-2014 and 2011-2012 for oral vancomycin and fidaxomicin, respectively. Guidelines or guidance documents for treating CDI and other infections should be updated in more timely fashion.
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Affiliation(s)
- Cornelius J Clancy
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Deanna Buehrle
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Michelle Vu
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Marilyn M Wagener
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - M Hong Nguyen
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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8
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Evaluation of Connecticut medical providers' concordance with 2017 IDSA/SHEA Clostridioides difficile treatment guidelines in New Haven County, 2018-2019. Infect Control Hosp Epidemiol 2020; 42:549-556. [PMID: 33234174 DOI: 10.1017/ice.2020.1237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES To assess Connecticut medical providers' concordance (2018-2019) with the 2017 Clostridioides difficile infection (CDI) treatment update by the Infectious Disease Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA). The effect of guideline concordance on CDI recurrence risk was also assessed. DESIGN Prospective, population-based study. SETTING New Haven County, Connecticut, from January 1, 2017, to December 31, 2019. PATIENTS CDI incident case (no positive tests in the prior 8 weeks), not limited by care setting. METHODS Using data from the Emerging Infections Program's CDI surveillance, severity and concordance were defined. Presence of megacolon and/or ileus defined fulminant disease; absence defined nonsevere/severe disease. Using 2017 treatment as baseline, 2018-2019 concordance was defined as receiving the recommended first-line antibiotic (ie, vancomycin or fidaxomicin for adult patients, vancomycin or metronidazole for pediatric patients) for exactly 10 days. For all analyses, significance was P < .05. RESULTS Among 990 cases, concordance increased from 24.8% in 2018 to 37.0% in 2019. First-line antibiotic concordance increased from 61.2% in 2018 to 79.9% in 2019. Recurrence risk was significantly associated with patients aged ≥65 years and was highest for those aged 75-84 years, but this factor was not significantly associated with concordance. CONCLUSIONS From 2018 through 2019, CDI treatment in New Haven County increasingly was concordant with the 2017 treatment update but remained low in 2019. Although concordance with treatment guidelines did not affect recurrence risk, close attention should be paid by medical providers to patients aged ≥65 years, specifically those aged 75-84 years because they are at an increased risk for recurrence.
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Scaria E, Powell WR, Birstler J, Alagoz O, Shirley D, Kind AJH, Safdar N. Neighborhood disadvantage and 30-day readmission risk following Clostridioides difficile infection hospitalization. BMC Infect Dis 2020; 20:762. [PMID: 33066737 PMCID: PMC7565791 DOI: 10.1186/s12879-020-05481-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 10/06/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Clostridioides difficile infection (CDI) is commonly associated with outcomes like recurrence and readmission. The effect of social determinants of health, such as 'neighborhood' socioeconomic disadvantage, on a CDI patient's health outcomes is unclear. Living in a disadvantaged neighborhood could interfere with a CDI patient's ability to follow post-discharge care recommendations and the success probability of these recommendations, thereby increasing risk of readmission. We hypothesized that neighborhood disadvantage was associated with 30-day readmission risk in Medicare patients with CDI. METHODS In this retrospective cohort study, odds of 30-day readmission for CDI patients are evaluated controlling for patient sociodemographics, comorbidities, and hospital and stay-level variables. The cohort was created from a random 20% national sample of Medicare patients during the first 11 months of 2014. RESULTS From the cohort of 19,490 patients (39% male; 80% white; 83% 65 years or older), 22% were readmitted within 30 days of an index stay. Unadjusted analyses showed that patients from the most disadvantaged neighborhoods were readmitted at a higher rate than those from less disadvantaged neighborhoods (26% vs. 21% rate: unadjusted OR = 1.32 [1.20, 1.45]). This relationship held in adjusted analyses, in which residence in the most disadvantaged neighborhoods was associated with 16% increased odds of readmission (adjusted OR = 1.16 [1.04, 1.28]). CONCLUSIONS Residence in disadvantaged neighborhoods poses a significantly increased risk of readmission in CDI patients. Further research should focus on in-depth assessments of this population to better understand the mechanisms underlying these risks and if these findings apply to other infectious diseases.
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Affiliation(s)
- Elizabeth Scaria
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, Madison, WI, 53706, USA
| | - W Ryan Powell
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Jen Birstler
- Department of Biostatics & Medical Informatics, University of Wisconsin-Madison, School of Medicine and Public Health, 201 WARF Building, 610 Walnut Street, Madison, WI, 53726, USA
| | - Oguzhan Alagoz
- Department of Industrial and Systems Engineering, University of Wisconsin-Madison, 1513 University Avenue, Madison, WI, 53706, USA.,Department of Population Health Sciences, University of Wisconsin-Madison, School of Medicine and Public Health, 707 WARF Building, 610 Walnut Street, Madison, WI, 53726, USA
| | - Daniel Shirley
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA
| | - Amy J H Kind
- Division of Geriatrics and Gerontology, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA.,Geriatric Research Education and Clinical Center, William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, 53705, USA
| | - Nasia Safdar
- Division of Infectious Diseases, Department of Medicine, University of Wisconsin-Madison, School of Medicine and Public Health, 1685 Highland Avenue, 5158 Medical Foundation Centennial Building, Madison, WI, 53705, USA. .,William S. Middleton Memorial Veterans Hospital, 2500 Overlook Terrace, Madison, WI, 53705, USA.
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10
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Treatment of Clostridioides difficile Infection and Non-compliance with Treatment Guidelines in Adults in 10 US Geographical Locations, 2013-2015. J Gen Intern Med 2020; 35:412-419. [PMID: 31768906 PMCID: PMC7018854 DOI: 10.1007/s11606-019-05386-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 06/28/2019] [Accepted: 08/21/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Infectious Diseases Society of America/Society for Healthcare Epidemiology of America (IDSA/SHEA) guidelines describe recommended therapy for Clostridioides difficile infection (CDI). OBJECTIVE To describe CDI treatment and, among those with severe CDI, determine predictors of adherence to the 2010 IDSA/SHEA treatment guidelines. DESIGN We analyzed 2013-2015 CDI treatment data collected through the Centers for Disease Control and Prevention's Emerging Infections Program. Generalized linear mixed models were used to identify predictors of guideline-adherent therapy. PATIENTS A CDI case was defined as a positive stool specimen in a person aged ≥ 18 years without a positive test in the prior 8 weeks; severe CDI cases were defined as having a white blood cell count ≥ 15,000 cells/μl. MAIN MEASURES Prescribing and predictors of guideline-adherent CDI therapy for severe disease. KEY RESULTS Of 18,243 cases, 14,257 (78%) were treated with metronidazole, 7683 (42%) with vancomycin, and 313 (2%) with fidaxomicin. The median duration of therapy was 14 (interquartile range, 11-15) days. Severe CDI was identified in 3250 (18%) cases; of 3121 with treatment data available, 1480 (47%) were prescribed guideline-adherent therapy. Among severe CDI cases, hospital admission (adjusted odds ratio [aOR] 2.48; 95% confidence interval [CI] 1.90, 3.24), age ≥ 65 years (aOR 1.37; 95% CI 1.10, 1.71), Charlson comorbidity index ≥ 3 (aOR 1.27; 95% CI 1.04, 1.55), immunosuppressive therapy (aOR 1.21; 95% CI 1.02, 1.42), and inflammatory bowel disease (aOR 1.56; 95% CI 1.13, 2.17) were associated with being prescribed guideline-adherent therapy. CONCLUSIONS Provider adherence to the 2010 treatment guidelines for severe CDI was low. Although the updated 2017 CDI guidelines, which expand the use of oral vancomycin for all CDI, might improve adherence by removing the need to apply severity criteria, other efforts to improve adherence are likely needed, including educating providers and addressing barriers to prescribing guideline-adherent therapy, particularly in outpatient settings.
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11
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Murray TS, Herbst J. The Ethics of Fecal Microbiota Transplant as a Tool for Antimicrobial Stewardship Programs. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2019; 47:541-554. [PMID: 31957576 DOI: 10.1177/1073110519897730] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Multidrug resistant organisms (MDROs) are a public health threat that have reduced the effectiveness of many available antibiotics. Antimicrobial stewardship programs (ASPs) have been tasked with reducing antibiotic use and therefore the emergence of MDROs. While fecal microbiota transplant (FMT) has been proposed as therapy to reduce patient colonization of MDROs, this will require additional evidence to support an expansion of the current clinical indication for FMT. This article discusses the evidence and ethics of the expanded utilization of FMT by ASPs for reasons other than severe recurrent or refractory Clostridioides (formerly Clostridium) difficile infection.
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Affiliation(s)
- Thomas S Murray
- Thomas S. Murray, M.D., Ph.D., is affiliated with Yale School of Medicine, Department of Pediatrics Section Infectious Diseases, New Haven CT. Jennifer Herbst, J.D., M.Bioethics, LL.M., is affiliated with Quinnipiac University School of Law and Frank H. Netter, MD, School of Medicine, North Haven CT
| | - Jennifer Herbst
- Thomas S. Murray, M.D., Ph.D., is affiliated with Yale School of Medicine, Department of Pediatrics Section Infectious Diseases, New Haven CT. Jennifer Herbst, J.D., M.Bioethics, LL.M., is affiliated with Quinnipiac University School of Law and Frank H. Netter, MD, School of Medicine, North Haven CT
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12
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Yin J, Kociolek LK, Same RG, Hsu AJ, Amoah J, Tamma PD. Oral Vancomycin May Be Associated With Earlier Symptom Resolution Than Metronidazole for Hospitalized Children With Nonsevere Clostridiodes difficile Infections. Open Forum Infect Dis 2019; 6:ofz492. [PMID: 31950069 PMCID: PMC6954469 DOI: 10.1093/ofid/ofz492] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 11/12/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE National guidelines recommend oral vancomycin over oral metronidazole as first-line treatment for nonsevere Clostridioides difficile infection (CDI) in adults. Guidelines recommend metronidazole for children with nonsevere CDI, emphasizing that comparative effectiveness studies comparing the relative efficacy of vancomycin and metronidazole are lacking in children. METHOD We conducted an observational study of hospitalized children with nonsevere CDI treated with metronidazole versus vancomycin using an inverse probability of treatment-weighted propensity-score analysis. All of the following criteria had to be present for children with positive CDI testing for study eligibility: (1) ≥3 new-onset unformed stools within a 24-hour period; (2) 2-17 years of age; (3) hospitalization for ≥48 hours for CDI; (4) no laxative use ≤48 hours; (5) no alternate etiology for diarrhea; (6) no previous episode of CDI ≤3 months; (7) no concurrent non-CDI-targeted antibiotic therapy, and (8) no severe or fulminant CDI. RESULTS One hundred ninety-two patients met eligibility criteria; 141 (73.4%) received oral metronidazole and 51 (26.6%) children received oral vancomycin. Baseline characteristics were similar between the 2 groups in the weighted cohort. Of 141 patients, 101 (71.7%) children receiving metronidazole had clinical improvement by day 5, whereas 44 of 51 (86.3%) cases resolved with vancomycin (odds ratio, 0.40; 95% confidence interval, 0.17-0.97; P = .04). The odds of CDI recurrence within 12 weeks were similar between the groups. CONCLUSIONS Our study suggests that children with nonsevere CDI have earlier resolution of clinical symptoms when prescribed vancomycin compared with metronidazole. Large interventional studies are necessary to evaluate the reproducibility of our findings.
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Affiliation(s)
- Jianyi Yin
- Division of Gastroenterology and Hepatology, Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Larry K Kociolek
- Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Rebecca G Same
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Alice J Hsu
- The Johns Hopkins Hospital, Department of Pharmacy, Baltimore, Maryland
| | - Joe Amoah
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Pranita D Tamma
- Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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13
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Chiu CY, Sarwal A, Feinstein A, Hennessey K. Effective Dosage of Oral Vancomycin in Treatment for Initial Episode of Clostridioides difficile Infection: A Systematic Review and Meta-Analysis. Antibiotics (Basel) 2019; 8:antibiotics8040173. [PMID: 31581576 PMCID: PMC6963925 DOI: 10.3390/antibiotics8040173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Revised: 09/08/2019] [Accepted: 09/25/2019] [Indexed: 12/23/2022] Open
Abstract
Background: Oral vancomycin is a first line treatment for an initial episode of Clostridioides difficile infection. However, the comparative efficacy of different dosing regimens is lacking evidence in the current literature. Methods: We searched PubMed, Embase, Cochrane Library, and ClinicalTrials.gov. from inception to May 2019. Only articles published in English are reviewed. This meta-analysis compares the effects of low dose oral vancomycin (<2 g per day) versus high dose vancomycin (2 g per day) for treatment of initial Clostridioides difficile infection. Results: One randomized controlled trial and two retrospective cohort studies are included. A total of 137 patients are identified, 53 of which were treated with low dose oral vancomycin (39%) and 84 with high dose oral vancomycin (61%). There is no significant reduction in recurrence rates with high dose vancomycin compared to low dose vancomycin for treating initial episodes of non-fulminant Clostridioides difficile infection ((odds ratio (OR) 2.058, 95%, confidence interval (CI): 0.653 to 6.489). Conclusions: Based on limited data in the literature, low dose vancomycin is no different than high dose vancomycin for treatment of an initial episode of Clostridioides difficile infection in terms of recurrence rate. Additional large clinical trials comparing the different dosages of vancomycin in initial Clostridioides difficile infection are warranted.
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Affiliation(s)
- Chia-Yu Chiu
- Department of Internal Medicine, Lincoln Medical Center, New York, NY 10451, USA.
| | - Amara Sarwal
- Department of Internal Medicine, Lincoln Medical Center, New York, NY 10451, USA.
| | - Addi Feinstein
- Department of Internal Medicine, Section of Infectious Diseases, Lincoln Medical Center, New York, NY 10451, USA.
| | - Karen Hennessey
- Department of Internal Medicine, Section of Infectious Diseases, Lincoln Medical Center, New York, NY 10451, USA.
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14
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Brown CC, Manis MM, Bohm NM, Curry SR. Oral Vancomycin for Secondary Prophylaxis of Clostridium difficile Infection. Ann Pharmacother 2018; 53:396-401. [PMID: 30450942 DOI: 10.1177/1060028018815170] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To summarize and critically appraise the evidence regarding oral vancomycin prophylaxis (OVP) to prevent recurrent Clostridium difficile infections (RCDIs), identify potential consequences of this emerging practice, and highlight future directions of study. DATA SOURCES A MEDLINE literature search of English-language publications from 1947 through September 2018 was performed using the search terms vancomycin and C difficile and prophylaxis. Clinical trials were identified on the National Library of Medicine clinical trials registry. STUDY SELECTION AND DATA EXTRACTION All clinical studies (n = 3) assessing oral vancomycin for secondary prophylaxis of C difficile infection (CDI) were evaluated by all authors. Other search results and references in selected publications were used for background and discussion. DATA SYNTHESIS OVP reduced the risk of RCDI in high-risk patients taking systemic antibiotics. Variable dosing regimens and lack of safety data are limitations. OVP may have an adverse impact on the gastrointestinal microbiome, but this was not examined in the clinical studies. Relevance to Patient Care and Clinical Practice: Although current studies are limited by methodological concerns, clinicians can consider vancomycin 125 mg orally once or twice daily in high-risk patients receiving broad-spectrum antibacterial agents. Results of ongoing trials will define the most appropriate regimen and its impact on outcomes, including collateral damage. CONCLUSIONS OVP reduces the risk of RCDIs and should be considered on a case-by-case basis. Caution is warranted before routine use is implemented because the impact on long-term outcomes has not been assessed and the optimal regimen has not been defined.
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Affiliation(s)
- Chase C Brown
- 1 Medical University of South Carolina, Charleston, SC, USA
| | - Melanie M Manis
- 2 Samford University McWhorter School of Pharmacy, Birmingham, AL, USA
| | - Nicole M Bohm
- 1 Medical University of South Carolina, Charleston, SC, USA.,3 Medical University of South Carolina College of Pharmacy, Charleston, SC, USA
| | - Scott R Curry
- 1 Medical University of South Carolina, Charleston, SC, USA
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15
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Ford DC, Schroeder MC, Ince D, Ernst EJ. Cost-effectiveness analysis of initial treatment strategies for mild-to-moderate Clostridium difficile infection in hospitalized patients. Am J Health Syst Pharm 2018; 75:1110-1121. [DOI: 10.2146/ajhp170554] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Diana C. Ford
- Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Mary C. Schroeder
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
| | - Dilek Ince
- Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Erika J. Ernst
- Division of Health Services Research, University of Iowa College of Pharmacy, Iowa City, IA
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16
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Goldstein EJC, Citron DM, Tyrrell KL, Leoncio E. In vitro stability of three oral vancomycin preparations stored at 2- 5 °C and ambient room temperature for up to 60 days against 100 Clostridioides (Clostridium) difficile and 51Staphylococcus aureus strains. Anaerobe 2018; 52:83-85. [PMID: 29902515 DOI: 10.1016/j.anaerobe.2018.06.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Revised: 06/03/2018] [Accepted: 06/05/2018] [Indexed: 10/14/2022]
Abstract
Oral vancomycin is used to treat Clostridioides (Clostridium) difficile infection. Several different preparations are available including reconstituted IV solutions, vancomycin capsules, and grape flavored vancomycin oral solution kit (CutisPharma). The shelf life for IV after reconstitution varies between 7 and 14 days under refrigeration, and a standard 30 days for vancomycin oral solution kit (CutisPharma). The impact of storage on the in vitro potency was determined in 3 different vancomycin preparations by measuring MICs for 100 strains of C. difficile and 25 strains of Staphylococcus aureus, at T0, 14, 30, and 60 days, stored at ambient (RT) and refrigerated (2-5 °C) temperatures. All vancomycin preparations showed potency over a period of 60 days regardless of storage conditions. However, the capsule preparation showed mold after 60 days at room temperature, but unlike vancomycin oral solution kit, which retained a clear appearance, the IV and capsule preps showed evidence of crystallization.
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Affiliation(s)
- Ellie J C Goldstein
- R. M. Alden Research Lab, Culver City, CA, United States; The UCLA School of Medicine, Los Angeles, CA, United States.
| | - Diane M Citron
- R. M. Alden Research Lab, Culver City, CA, United States
| | | | - Eliza Leoncio
- R. M. Alden Research Lab, Culver City, CA, United States
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17
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Reducing Clostridium difficile Colitis Rates Via Cost-Saving Diagnostic Stewardship. Infect Control Hosp Epidemiol 2018; 39:734-736. [DOI: 10.1017/ice.2018.51] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
We conducted a quality improvement project at a large public tertiary-care academic hospital to reduce reported hospital-acquired Clostridium difficile infection (CDI) rates. We introduced diagnostic stewardship and provider education, resulting in a 2-fold reduction in C. difficile nucleic acid amplification test (NAAT) orders and markedly lower hospital CDI rate.Infect Control Hosp Epidemiol 2018;39:734–736
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