Mild SARS-CoV-2 infection in vulnerable patients: implementation of a clinical pathway for early treatment

INTRODUCTION

The objective of this report is to describe the clinical pathway for early treatment of patients with acute SARS-CoV-2 infection and to evaluate the first results of its implementation.

METHODS

This is a descriptive and retrospective study of the implementation of a clinical pathway of treatment in outpatients (January 1 to June 30 2022). Clinical pathway: detection and referral systems from Primary Care, Emergency services, hospital specialities and an automated detection system; clinical evaluation and treatment administration in the COVID-19 day-hospital and subsequent clinical follow-up. Explanatory variables: demographics, comorbidity, vaccination status, referral pathways and treatment administration.

OUTCOME VARIABLES

hospitalization and death with 30 days, grade 2-3 toxicity related to treatment.

RESULTS

Treatment was administered to 262 patients (53,4% women, median age 60 years). The treatment indication criteria were immunosupression (68,3%), and the combination of age, vaccination status and comorbidity in the rest 47,3% of the patients s received remdesivir, 35,9% nirmatrelvir/ritonavir, 13,4% sotrovimab and 2,4% combined treatment with a median of 4 days after symptom onset. Hospital admission was required for 6,1% of the patients, 3,8% related to progression COVID-19. No patient died. Toxicity grade 2-3 toxicity was reported in 18,7%, 89,8% dysgeusia and metallic tasted related nirmatrelvir/ritonavir. Seven patients discontinued treatment due to toxicity.

CONCLUSION

The creation and implementation of a clinical pathway for non-hospitalized patients with SARS-CoV-2 infection is effective and it allows early accessibility and equity of currently available treatments.

Antiparkinsonian Medication Reconciliation as a Strategy to Improve Safety by Preventing Medication Errors

Background

About 70% of neurologists report that PD patients do not get their medication properly when hospitalized, and 33% are prescribed contraindicated drugs.

Objectives

To execute medication reconciliation (MedRec) focused on antiparkinsonian drugs to identify, characterize and, eventually, prevent medication errors, thus promoting therapeutic quality and safety in daily practice.

Methods

An interventional, single-center, 1 year, prospective study. All the patients who were hospitalized and had, at least, one active prescription containing an antiparkinsonian drug at hospital admission were included. MedRec was performed by following a three-phased check: inpatient electronic prescription validation after assessing the outpatient medication schedule, review of the latest clinical report emitted by the Neurology Department/General Practitioner, and pharmacist-driven interview of the patient and/or caregiver to confirm the information regarding medication gathered.

Results

A total of 171 admission episodes from 132 patients were registered (February 1, 2021, and January 31, 2022). Of 224 prescription lines involving antiparkinsonian drugs, 179 contained, at least, one medication error (59.8%). Commission errors (91.62%) were more frequent than omitted drugs (8.38%). The most common medication errors were related to timing (41.90%), frequency (21.23%), and dosing (19.55%). The implementation of this program prevented the erroneous administration of 2716 antiparkinsonian doses, 60% of the total number of doses prescribed. Interestingly, a significant relationship between the number of medication errors and having levodopa prescribed was evidenced (P < 0.05). A contraindicated drug was prescribed in almost one-third of the episodes (29.82%).

Conclusions

Clinical pharmacists' implementation of an antiparkinsonians reconciliation program sharply reduced medication errors and prescription of contraindicated drugs.

[Mild SARS-CoV-2 infection in vulnerable patients: implementation of a clinical pathway for early treatment]

INTRODUCTION

The objective of this report is to describe the clinical pathway for early treatment of patients with acute SARS-CoV-2 infection and to evaluate the first results of its implementation.

METHODS

This is a descriptive and retrospective study of the implementation of a clinical pathway of treatment in outpatients (January 1 to June 30 2022). Clinical pathway: detection and referral systems from Primary Care, Emergency services, hospital specialities and an automated detection system; clinical evaluation and treatment administration in the COVID-19 day-hospital and subsequent clinical follow-up. Explanatory variables: demographics, comorbidity, vaccination status, referral pathways and treatment administration.

OUTCOME VARIABLES

hospitalization and death with 30 days, grade 2-3 toxicity related to treatment.

RESULTS

Treatment was administered to 262 patients (53,4% women, median age 60 years). The treatment indication criteria were immunosupression (68,3%), and the combination of age, vaccination status and comorbidity in the rest47,3% of the patients s received remdesivir, 35,9% nirmatrelvir/ritonavir, 13,4% sotrovimab and 2,4% combined treatment with a median of 4 days after symptom onset. Hospital admission was required for 6,1% of the patients, 3,8% related to progression COVID-19. No patient died. Toxicity grade 2-3 toxicity was reported in 18,7%, 89,8% dysgeusia and metallic tasted related nirmatrelvir/ritonavir. Seven patients discontinued treatment due to toxicity.

CONCLUSION

The creation and implementation of a clinical pathway for non-hospitalized patients with SARS-CoV-2 infection is effective and it allows early accessibility and equity of currently available treatments.

Impact of COVID19 pandemic on the incidence of health-care associated Clostridioides difficile infection

OBJECTIVE

To investigate the impact of COVID19 pandemic on the incidence of health-care associated Clostridioides difficile infection (HA-CDI).

METHODS

Retrospective study conducted in the Hospital Universitario de Valme (HUV) and the Hospital General Universitario de Alicante (HGUA) in Spain between January 2019 and February 2021. The study period was divided into non-COVID19 period (2019 and months from 2020 to 2021 with ≤30 hospitalized COVID19 patients) and COVID19 period (months from 2020 to 2021 with >30 COVID19 patients). HA-CDI incidence rates (IR) were calculated as the number of new CDI cases per 10.000 occupied bed-days (OBD) and antimicrobial consumption by means of the defined daily dose (DDD) per 1000 OBD.

RESULTS

During the COVID19 period, HA-CDI IR in the HUV was 2.6 per 10.000 OBD, which was lower than what was observed during the non-COVID19 period (4.1 per 10.000 OBD; p = 0.1). In the HGUA, HA-CDI IR during COVID19 period was 3.9 per 10.000 OBD, which was not significantly different to the IR observed during the non-COVID19 period (3.7 per 10.000 OBD; p = 0.8). There was a slight increase in the total antibiotic consumption during COVID19 period in both hospitals, with significant increases of certain high-risk antibiotics as cephalosporins.

CONCLSUSIONS

HA-CDI incidence has not increased during the COVID19 pandemic in two tertiary centers in Spain, in spite of a slightly higher antibiotic consumption during the COVID19 period in both hospitals. These findings suggest that, in the presence of strict infection control measures, hospital antibiotic consumption might have a lower impact than expected on HA-CDI.

FRAX-based intervention and assessment thresholds in seven Latin American countries

Age-specific intervention and assessment thresholds were developed for seven Latin American countries. The intervention threshold ranged from 1.2% (Ecuador) to 27.5% (Argentina) at the age of 50 and 90 years, respectively. In the Latin American countries, FRAX offers a substantial advance for the detection of subjects at high fracture risk.

INTRODUCTION

Intervention thresholds are proposed using the Fracture Risk Assessment (FRAX) tool. We recommended their use to calculate the ten-year probability of fragility fracture (FF) in both, men and women with or without the inclusion of bone mineral density (BMD). The purpose of this study is to compute FRAX-based intervention and BMD assessment thresholds for seven Latin American countries in men and women ≥ 40 years.

METHODS

The intervention threshold (IT) was set at a 10-year probability of a major osteoporotic fracture (MOF) equivalent to a woman with a prior FF and a body mass index (BMI) equal to 25.0 kg/m² without BMD or other clinical risk factors. The lower assessment threshold was set at a 10-year probability of a MOF in women with BMI equal to 25.0 kg/m², no previous fracture and no clinical risk factors. The upper assessment threshold was set at 1.2 times the IT.

RESULTS

For the seven LA countries, the age-specific IT varied from 1.5 to 27.5% in Argentina, 3.8 to 25.2% in Brazil, 1.6 up to 20.0% in Chile, 0.6 to 10.2% in Colombia, 0.9 up to 13.6% in Ecuador, 2.6 to 20.0% in Mexico, and 0.7 up to 22.0% in Venezuela at the age of 40 and 90 years, respectively.

CONCLUSIONS

In the LA countries, FRAX-based IT offers a substantial advance for the detection of men and women at high fracture risk, particularly in the elderly. The heterogeneity of IT between the LA countries indicates that country-specific FRAX models are appropriate rather than a global LA model.

Impact of a stewardship program on bacteraemia in adult inpatients

OBJECTIVE

Bloodstream infections (BSIs) are associated with considerable morbidity and mortality among inpatients. The aim of this study was to evaluate the impact of a stewardship program on clinical and antimicrobial therapy-related outcomes in patients with bacteraemia.

METHODS

Single-centre, before-and-after quasi-experimental study in adult inpatients. Over 1 January 2013 to 31 June 2013 all patients aged 18 years or older with a bacteraemia (interven-tion group, N=200) were compared to a historical cohort (1 Janu-ary 2012 to 31 December 2012) (control group, N=200).

RESULTS

Following blood culture results and adjusting for potential confounders, the stewardship program was associated with more changes to antibiotic regimens (adjusted odds ratio [ORa]: 4.6, 95% CI 2.9, 7.4), more adjustments to antimicrobial therapy (ORa: 2.4, 95% CI 1.5, 3.8), and better source control in the first five days (ORa 1.6, 95% CI: 1.0, 2.7). In the subgroup that initially received inappropriate empiric treatment (n=138), the intervention was associated with more antibiotic changes (OR: 3.9, 95% CI: 1.8, 8.5) and a better choice of definitive antimicrobial therapy (OR 2.3 95% CI: 1.2, 4.6). There were also more antibiotic changes in the subgroups with both Gram-negative (OR: 2.8, 95% CI: 1.6, 4.9; n=217) and Gram-positive (OR: 4.6, 95% CI: 1.8, 9.9; n=135) bacteraemia among those receiving the intervention, while the Gram-positive subgroup also received more appropriate definitive antimicrobial therapy (OR: 3.9, 95% CI: 1.8, 8.8).

CONCLUSIONS

The stewardship program improved treatment of patients with bacteraemia and appropriateness of therapy.

Possibility to deduce the emission time sequence of neutrons and protons from the neutron-proton correlation function

Experimental information has been derived from the neutron-proton correlation function in order to deduce the time sequence of neutrons and protons emitted at 45 degrees in the E/A = 45 MeV 58Ni + 27Al reaction.

Prevalence of Raynaud's phenomenon in a healthy Spanish population

To determine the prevalence of Raynaud's phenomenon (RP) in Spain, we studied a working population of 988 men and 479 women. The overall prevalence of RP was 3.7%, with a 3.2% rate for men and 4.7% for women. There was a statistically significant association between Raynaud's phenomenon and a personal or familial history of perniosis, acrocyanosis or migraine among women. The age at onset was significantly lower in women. RP was classified as primary in 89% of the cases and as secondary in 11%. Examination by capillaroscopy revealed no significant differences between primary Raynaud cases and controls.

First exchange neutrophilia: an index of peritonitis during chronic intermittent peritoneal dialysis

During intermittent peritoneal dialysis (IPD) early diagnosis of peritonitis may be difficult, because of paucity in clinical signs and delays in bacteriologic studies. We examined prospectively leucocyte counts and their differential composition in initial ascites and dialysis effluent of patients on IPD and correlated these findings to the presence of subsequently bacteriologically proven clinical peritonitis. Total leucocyte counts from either ascites or first exchange effluent did not differentiate infected from noninfected patients. In contrast, first exchange effluent neutrophilia (greater than 43%) proved to be an early indicator of infection, being 100% sensitive and 94% specific for peritonitis. We conclude that in such patients peritoneal effluent neutrophilia should be considered an indication of possible infection.