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Sine K, Lavoie T, Caffrey AR, Lopes VV, Dosa D, LaPlante KL, Appaneal HJ. Exploring variations in recommended first-choice therapy for complicated urinary tract infections in males: Insights from outpatient settings across age, race, and ethnicity. Pharmacotherapy 2024; 44:308-318. [PMID: 38483080 DOI: 10.1002/phar.2912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 01/31/2024] [Accepted: 02/04/2024] [Indexed: 04/25/2024]
Abstract
INTRODUCTION There are known disparities in the treatment of infectious diseases. However, disparities in treatment of complicated urinary tract infections (UTIs) are largely uninvestigated. OBJECTIVES We characterized UTI treatment among males in Veterans Affairs (VA) outpatient settings by age, race, and ethnicity and identified demographic characteristics predictive of recommended first-choice antibiotic therapy. METHODS We conducted a national, retrospective cohort study of male VA patients diagnosed with a UTI and dispensed an outpatient antibiotic from January 2010 through December 2020. Recommended first-choice therapy for complicated UTI was defined as use of a recommended first-line antibiotic drug choice regardless of area of involvement (ciprofloxacin, levofloxacin, or sulfamethoxazole/trimethoprim) and a recommended duration of 7 to 10 days of therapy. Multivariable models were used to identify demographic predictors of recommended first-choice therapy (adjusted odds ratio [aOR] > 1). RESULTS We identified a total of 157,898 males diagnosed and treated for a UTI in the outpatient setting. The average antibiotic duration was 9.4 days (±standard deviation [SD] 4.6), and 47.6% of patients were treated with ciprofloxacin, 25.1% with sulfamethoxazole/trimethoprim, 7.6% with nitrofurantoin, and 6.6% with levofloxacin. Only half of the male patients (50.6%, n = 79,928) were treated with recommended first-choice therapy (first-line drug choice and appropriate duration); 77.6% (n = 122,590) were treated with a recommended antibiotic choice and 65.9% (n = 104,070) with a recommended duration. Age 18-49 years (aOR 1.07, 95% confidence interval [CI] 1.03-1.11) versus age ≥65 years was the only demographic factor predictive of recommended first-choice therapy. CONCLUSIONS Nearly half of the patients included in this study did not receive recommended first-choice therapies; however, racial and ethnic disparities were not identified. Underutilization of recommended first-choice antibiotic therapy in complicated UTIs continues to be an area of focus for antimicrobial stewardship programs.
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Affiliation(s)
- Kathryn Sine
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Thomas Lavoie
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - David Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Kerry L LaPlante
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
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Caffrey AR, Appaneal HJ, Lopes VV, Riccobene TA, LaPlante KL. Real-world utilization of ceftazidime/avibactam among inpatients in the national Veterans Affairs Healthcare System. Am J Health Syst Pharm 2024:zxae038. [PMID: 38365226 DOI: 10.1093/ajhp/zxae038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Indexed: 02/18/2024] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE Multidrug-resistant (MDR) infections are challenging to treat due to underlying patient conditions, pathogen characteristics, and high antibiotic resistance rates. As newer antibiotic therapies come to market, limited data exist about their real-world utilization. METHODS This was a national retrospective cohort study of ceftazidime/avibactam (approved in 2015) utilization among inpatients from the Veterans Affairs (VA) Healthcare System, from 2015 through 2021. Joinpoint regression was used to estimate time trends in utilization. RESULTS Ceftazidime/avibactam use increased by 52.3% each year (days of therapy per 1,000 bed days; 95% confidence interval, 12.4%-106.4%). We identified 1,048 unique predominantly male (98.3%) and white (66.2%; Black, 27.7%) patients treated with ceftazidime/avibactam, with a mean (SD) age of 71.5 (11.9) years. The most commonly isolated organisms were Pseudomonas aeruginosa (36.3%; carbapenem resistant, 80.6%; MDR, 65.0%) and Klebsiella species (34.1%; carbapenem resistant, 78.4%; extended-spectrum cephalosporin resistant, 90.7%). Common comorbid conditions included hypertension (74.8%), nervous system disorders (60.2%), diabetes mellitus (48.7%), and cancer (45.1%). Median time to ceftazidime/avibactam initiation from admission was 6 days, with a median of 3 changes in therapy before ceftazidime/avibactam initiation and a subsequent median length of inpatient stay of 14 days (median of 8 days of ceftazidime/avibactam therapy). Treatment heterogeneity was high, both before ceftazidime/avibactam initiation (89.6%) and during ceftazidime/avibactam treatment (85.6%), and common concomitant antibiotics included vancomycin (41.4%), meropenem (24.1%), cefepime (15.2%), and piperacillin/tazobactam (15.2%). The inpatient mortality rate was 23.6%, and 20.8% of patients had a subsequent admission with ceftazidime/avibactam treatment. CONCLUSION Utilization of ceftazidime/avibactam increased from 2015 to 2021 in the national VA Healthcare System. Ceftazidime/avibactam was utilized in complex, difficult-to-treat patients, with substantial treatment heterogeneity and variation in the causative organism and culture site.
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Affiliation(s)
- Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, College of Pharmacy, University of Rhode Island, Kingston, RI, and School of Public Health, Brown University, Providence, RI, USA
| | - Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | | | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, College of Pharmacy, University of Rhode Island, Kingston, RI, and School of Public Health, Brown University, Providence, RI, USA
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Appaneal HJ, LaPlante KL, Lopes VV, Martin C, Puzniak L, Wiemken TL, Zasowski EJ, McLaughlin JM, Caffrey AR. Nirmatrelvir/Ritonavir Utilization for the Treatment of Non-hospitalized Adults with COVID-19 in the National Veterans Affairs (VA) Healthcare System. Infect Dis Ther 2024; 13:155-172. [PMID: 38217842 PMCID: PMC10828173 DOI: 10.1007/s40121-023-00910-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/15/2023] [Indexed: 01/15/2024] Open
Abstract
INTRODUCTION Limited data exist regarding real-world utilization of nirmatrelvir/ritonavir. We identified predictors of nirmatrelvir/ritonavir use among Veterans Affairs (VA) outpatients nationally. METHODS We conducted a retrospective cohort study among outpatients with coronavirus disease 2019 (COVID-19) who were eligible to receive nirmatrelvir/ritonavir between January and December of 2022, to identify factors associated with nirmatrelvir/ritonavir use (i.e., demographics, medical history, prior medication and healthcare exposures, frailty, and other clinical characteristics) using multivariable logistic regression. RESULTS We included 309,755 outpatients with COVID-19 who were eligible for nirmatrelvir/ritonavir, of whom 12.2% received nirmatrelvir/ritonavir. Nirmatrelvir/ritonavir uptake increased from 1.1% to 23.2% over the study period. Factors associated with nirmatrelvir/ritonavir receipt included receiving a COVID-19 booster vs. none (adjusted odds ratio [aOR] 2.19 [95% confidence interval [CI] 2.12-2.26]), age ≥ 50 vs. 18-49 years (aORs > 1.5 for all age groups ≥ 50 years), having HIV (aOR 1.36 [1.22-1.51]), being non-frail vs. severely frail (aOR 1.22 [1.13-1.33]), and having rheumatoid arthritis (aOR 1.12 [1.04-1.21). Those with concomitant use of potentially interacting antiarrhythmics (aOR 0.35 [0.28-0.45]), anticoagulants/antiplatelets (aOR 0.42 [0.40-0.45]), and/or psychiatric/sedatives (aOR 0.84 [0.81-0.87]) were less likely to receive nirmatrelvir/ritonavir. CONCLUSIONS Despite increases over time, overall utilization of nirmatrelvir/ritonavir was low. Predictors of nirmatrelvir/ritonavir utilization were consistent with known risk factors for progression to severe COVID-19, including older age and underlying medical conditions. Unvaccinated and undervaccinated patients and those receiving potentially interacting medications for cardiovascular or mental health conditions (antiarrhythmic, alpha-1 antagonist, anticoagulant/antiplatelet, sedative/hypnotic/psychiatric) were less likely to receive nirmatrelvir/ritonavir. Further education of prescribers and patients about nirmatrelvir/ritonavir treatment guidelines is needed to improve overall uptake and utilization in certain high-risk subpopulations.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Rd, 265B, Kingston, RI, 02881, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Rd, 265B, Kingston, RI, 02881, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | | | | | | | | | | | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Rd, 265B, Kingston, RI, 02881, USA.
- School of Public Health, Brown University, Providence, RI, USA.
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Lavoie T, Appaneal HJ, LaPlante KL. Advancements in Novel Live Biotherapeutic Products for Clostridioides difficile Infection Prevention. Clin Infect Dis 2023; 77:S447-S454. [PMID: 38051964 DOI: 10.1093/cid/ciad639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Indexed: 12/07/2023] Open
Abstract
The profound impact of the human microbiome on health and disease has captivated the interest of clinical and scientific communities. The human body hosts a vast array of microorganisms collectively forming the human microbiome, which significantly influences various physiological processes and profoundly shapes overall well-being. Notably, the gut stands out as an exceptional reservoir, harboring the most significant concentration of microorganisms, akin to an organ in itself. The gut microbiome's composition and function are influenced by genetics, environment, age, underlying conditions, and antibiotic usage, leading to dysbiosis and pathogenesis, such as Clostridioides difficile infection (CDI). Conventional CDI treatment, involving antibiotics like oral vancomycin and fidaxomicin, fails to address dysbiosis and may further disrupt gut microbial communities. Consequently, emerging therapeutic strategies are focused on targeting dysbiosis and restoring gut microbiota to advance CDI therapeutics. Fecal microbiota transplantation (FMT) has demonstrated remarkable efficacy in treating recurrent CDI by transferring processed stool from a healthy donor to a recipient, restoring gut dysbiosis and enhancing bacterial diversity. Moreover, 2 newer Food and Drug Administration (FDA)-approved live biotherapeutic products (LBP), namely, Fecal Microbiota Live-JSLM and Fecal Microbiota Spores Live-BRPK, have shown promise in preventing CDI recurrence. This review explores the role of the gut microbiota in preventing and treating CDI, with an emphasis on gut-based interventions like FMT and fecal microbiota-based products that hold potential for gut restoration and prevention of CDI recurrence. Understanding the microbiome's impact on CDI prevention and treatment offers valuable insights for advancing future CDI therapeutics.
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Affiliation(s)
- Thomas Lavoie
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
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Appaneal HJ, Lesniak K, LaPlante KL, Feret B. Student pharmacists delivering academic detailing on adult pneumococcal vaccination to community pharmacists. J Am Pharm Assoc (2003) 2023; 63:1064-1069.e2. [PMID: 37031953 DOI: 10.1016/j.japh.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 03/21/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023]
Abstract
BACKGROUND Academic detailing is an educational outreach approach to disseminate evidence-based information to health care professionals and improve clinical decision making. Pharmacists and physicians are recognized as the most qualified individuals to perform academic detailing; however, trained student pharmacists may also serve as suitable academic detailers. OBJECTIVES To describe our academic detailing intervention that used trained student pharmacists to disseminate an updated pneumococcal vaccination clinical pathway (i.e., decision-support tool) and education to community pharmacists in Rhode Island and Massachusetts. METHODS We updated an academic detailing initiative that included a pneumococcal vaccination clinical pathway and education for community pharmacists in 2021. Two University of Rhode Island (URI) College of Pharmacy pharmacist faculty members trained 6 student pharmacists to perform academic detailing. Student pharmacists visited URI-affiliated community pharmacies throughout Rhode Island and Massachusetts. After each session, each participant received a 6-question anonymous paper survey to assess the effectiveness of the updated pathway and academic detailing session. The survey used a 5-point Likert-type scale. We assessed the percentage agreement with each question. RESULTS Academic detailing was delivered to 76 community pharmacists from May to August 2021. Most respondents agreed (89.2%, 58/65) that their knowledge of which patient populations met eligibility for the pneumococcal conjugate vaccine or pneumococcal polysaccharide vaccine improved. Respondents were confident they could apply the knowledge gained (93.8%, 61/65) and intended to apply the pathway (93.8%, 61/65) to clinical practice. Most respondents expected vaccination practices to change because of the academic detailing and education materials received (83.6%, 51/61). Almost all respondents (95.4%, 62/65) found the educational materials easy to understand. CONCLUSION Trained student pharmacists can deliver academic detailing regarding adult pneumococcal vaccination to community pharmacists. Enlisting the help of student pharmacists may be a sustainable approach to academic detailing and provides students with valuable opportunities to practice delivering educational outreach to community pharmacists.
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Liao JX, Appaneal HJ, Menon A, Lopes V, LaPlante KL, Caffrey AR. Decreasing Antibiotic Resistance Trends Nationally in Gram-Negative Bacteria Across United States Veterans Affairs Medical Centers, 2011-2020. Infect Dis Ther 2023:10.1007/s40121-023-00827-9. [PMID: 37326931 PMCID: PMC10390413 DOI: 10.1007/s40121-023-00827-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 05/19/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Gram-negative resistance is a well-acknowledged public health threat. Surveillance data can be used to monitor resistance trends and identify strategies to mitigate their threat. The objective of this study was to assess antibiotic resistance trends in Gram-negative bacteria. METHODS The first cultures of Pseudomonas aeruginosa, Citrobacter, Escherichia coli, Enterobacter, Klebsiella, Morganella morganii, Proteus mirabilis, and Serratia marcescens per hospitalized patient per month collected from 125 Veterans Affairs Medical Centers (VAMCs) between 2011 to 2020 were included. Time trends of resistance phenotypes (carbapenem, fluoroquinolone, extended-spectrum cephalosporin, multi-drug, and difficult-to-treat) were analyzed with Joinpoint regression to estimate average annual percent changes (AAPC) with 95% confidence intervals and p values. A 2020 antibiogram of reported antibiotic percent susceptibilities was also created to evaluate resistance rates at the beginning of the COVID-19 pandemic. RESULTS Among 40 antimicrobial resistance phenotype trends assessed in 494,593 Gram-negative isolates, there were no noted increases; significant decreases were observed in 87.5% (n = 35), including in all P. aeruginosa, Citrobacter, Klebsiella, M. morganii, and S. marcescens phenotypes (p < 0.05). The largest decreases were seen in carbapenem-resistant phenotypes of P. mirabilis, Klebsiella, and M. morganii (AAPCs: - 22.9%, - 20.7%, and - 20.6%, respectively). In 2020, percent susceptibility was over 80% for all organisms tested against aminoglycosides, cefepime, ertapenem, meropenem, ceftazidime-avibactam, ceftolozane-tazobactam, and meropenem-vaborbactam. CONCLUSION We observed significant decreases in antibiotic resistance for P. aeruginosa and Enterobacterales over the past decade. According to the 2020 antibiogram, in vitro antimicrobial activity was observed for most treatment options. These results may be related to the robust infection control and antimicrobial stewardship programs instituted nationally among VAMCs.
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Affiliation(s)
- J Xin Liao
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA
| | - Anupama Menon
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
- Section of Infectious Diseases, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Vrishali Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA.
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA.
- Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA.
- School of Public Health, Brown University, Providence, RI, USA.
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Avenue, Providence, RI, 02908, USA.
- College of Pharmacy, University of Rhode Island, 7 Greenhouse Road, Kingston, RI, 02881, USA.
- School of Public Health, Brown University, Providence, RI, USA.
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Appaneal HJ, Lopes VV, LaPlante KL, Caffrey AR. Treatment, clinical outcomes, and predictors of mortality among a national cohort of hospitalized patients with Stenotrophomonas maltophilia infection. Public Health 2023; 214:73-80. [PMID: 36521275 DOI: 10.1016/j.puhe.2022.10.025] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Revised: 10/26/2022] [Accepted: 10/27/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVES To analyze treatment, clinical outcomes, and predictors of inpatient mortality in hospitalized patients with Stenotrophomonas maltophilia infection. STUDY DESIGN Retrospective cohort study. METHODS We included patients admitted to Veterans Affairs hospitals nationally with S. maltophilia cultures and treatment from 2010 to 2019. We described patient and clinical characteristics, antibiotic treatment, and clinical outcomes. Univariate and multivariable logistic regression were used to evaluate predictors of inpatient mortality. RESULTS We identified 3891 hospitalized patients treated for an S. maltophilia infection, of which 13.7% died during admission. The most common antibiotic agents were piperacillin/tazobactam (39.7%), sulfamethoxazole/trimethoprim (23.3%), and levofloxacin (23.2%). Combination therapy was used in 16.6% of patients. Independent predictors of inpatient mortality identified in multivariable analysis included the following: presence of current acute respiratory failure (adjusted odds ratio [aOR] 4.74, 95% confidence interval [CI] 3.63-6.19), shock (aOR 3.00, 95% CI 2.31-3.90), acute renal failure (aOR 2.06, 95% CI 1.64-2.60), and septicemia (aOR 1.90, 95% CI 1.49-2.42), age 65 years and older (aOR 2.05, 95% CI 1.07-3.94, reference age 18-49 years), hospital-acquired infection (aOR 1.87, 95% CI 1.48-2.37), Black (aOR 1.58, 95% CI 1.21-2.06) and other races (aOR 1.65, 95% CI 1.41-2.41, reference White), liver disease (aOR 1.51, 95% CI 1.02-2.22), and median Charlson comorbidity score or higher (aOR 1.36, 95% CI 1.08-1.71, reference less than median). Clinical outcomes were similar between patients infected with sulfamethoxazole/trimethoprim-resistant, levofloxacin-resistant, and multidrug-resistant S. maltophilia strains compared to non-resistant strains. CONCLUSIONS In our national cohort of hospitalized patients with S. maltophilia infection, 13.7% of patients died during admission and several predictors of inpatient mortality were identified. Predictors related to the severity of infection were among the strongest identified. It is important that in severely ill patients presenting to the hospital, S. maltophilia be considered as a cause.
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Affiliation(s)
- H J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA.
| | - V V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - K L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - A R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA.
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Caffrey AR, Appaneal HJ, Lopes VV, LaPlante KL. 651. Ceftazidime/avibactam utilization in the national Veterans Affairs (VA) Healthcare System. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
Multidrug-resistant infections are challenging to treat, due to underlying patient conditions, pathogen characteristics, and high resistance rates to antibiotic treatments. Ceftazidime/avibactam (CAZ-AVI, approved in 2015) is approved to treat complicated intra-abdominal infections, complicated urinary tract infections, hospital-acquired bacterial pneumonia, and ventilator-associated bacterial pneumonia. As newer antibiotic therapies come to market, limited data exist about their use in real-world practice. Therefore, we sought to describe the utilization of CAZ-AVI in clinical practice.
Methods
This national retrospective cohort study included hospitalized VA patients receiving CAZ-AVI from 2015 through 2021. Cultures, infection diagnoses, demographics, comorbidities, treatments, and clinical outcomes were assessed in this cohort.
Results
During the study period, 1,048 unique patients received CAZ-AVI, with a mean age of 71.5 (±11.9) years. The study cohort was predominantly male (98.3%) and White (66.2%, Black 27.7%). The most common organism-culture site combinations were Klebsiella-urine (19.6%), Pseudomonas aeruginosa-respiratory (14.0%), Pseudomonas aeruginosa-urine (10.1%), Escherichia coli-urine (6.9%) and Klebsiella-blood (6.9%). The median time to CAZ-AVI initiation from admission was 6 days, with a subsequent median 14-day hospital stay. Median length of CAZ-AVI therapy was 8 days. Most patients changed antibiotic therapy 3 times before starting CAZ-AVI. Treatment heterogeneity was high both prior to CAZ-AVI initiation (89.6%) and during CAZ-AVI treatment (85.6%). The most common concomitant antibiotic therapies during CAZ-AVI treatment were vancomycin (41.4%), meropenem (24.1%), cefepime (15.2%), and piperacillin/tazobactam (15.2%). Inpatient mortality in this cohort was 23.6%, and about one-third of patients had a subsequent hospitalization with CAZ-AVI treatment (35.1% in 2021).
Conclusion
Utilization of CAZ-AVI increased from 2015 to 2018 and has since stabilized in the national VA Healthcare System. CAZ-AVI has been utilized in complex, difficult-to-treat patients with substantial treatment heterogeneity and variation in causative organism-culture site.
Disclosures
Aisling R. Caffrey, PhD, M.S., AbbVie Inc.: Grant/Research Support|Gilead Sciences Inc.: Grant/Research Support|Merck & Co., Inc: Advisor/Consultant|Merck & Co., Inc: Grant/Research Support|Shionogi Inc.: Grant/Research Support Haley J. Appaneal, PharmD, Ph.D., Shionogi Inc: Grant/Research Support Kerry L. LaPlante, Pharm.D., FCCP, FIDSA, FIDP, AbbVie Inc.: Grant/Research Support|Gilead Sciences, Inc.: Grant/Research Support|Melinta Therapeutics, Inc.,: Grant/Research Support|Merck & Co., Inc.: Advisor/Consultant|Merck & Co., Inc.: Grant/Research Support|Nabriva Therapeutics US, Inc.,: Grant/Research Support|Ocean Spray Cranberries, Inc.: Grant/Research Support|Pfizer Pharmaceuticals: Grant/Research Support|Shionogi, Inc.: Grant/Research Support|Tetraphase Pharmaceuticals.: Grant/Research Support.
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Affiliation(s)
- Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- College of Pharmacy, University of Rhode Island , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- School of Public Health, Brown University , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
| | - Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- College of Pharmacy, University of Rhode Island , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- School of Public Health, Brown University , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center , Providence, RI , United States, Providence, Rhode Island
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- College of Pharmacy, University of Rhode Island , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
- Warren Alpert Medical School of Brown University, Division of Infectious Diseases , Providence, RI , United States ; , Providence, RI , United States ; , Kingston, RI , United States ; , Providence, RI, Kingston, Rhode Island
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Liao JX, Appaneal HJ, Vicent ML, Vyas A, LaPlante KL. Path of least recurrence: A systematic review and
meta‐analysis
of fidaxomicin versus vancomycin for
Clostridioides difficile
infection. Pharmacotherapy 2022; 42:810-827. [DOI: 10.1002/phar.2734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 09/19/2022] [Accepted: 09/21/2022] [Indexed: 11/06/2022]
Affiliation(s)
- J. Xin Liao
- Infectious Diseases Research Program Providence Veterans Affairs Medical Center Providence Rhode Island USA
- College of Pharmacy University of Rhode Island Kingston Rhode Island USA
| | - Haley J. Appaneal
- Infectious Diseases Research Program Providence Veterans Affairs Medical Center Providence Rhode Island USA
- College of Pharmacy University of Rhode Island Kingston Rhode Island USA
- Center of Innovation in Long‐Term Support Services Providence Veterans Affairs Medical Center Providence Rhode Island USA
| | - Martie L. Vicent
- Infectious Diseases Research Program Providence Veterans Affairs Medical Center Providence Rhode Island USA
- College of Pharmacy University of Rhode Island Kingston Rhode Island USA
| | - Ami Vyas
- College of Pharmacy University of Rhode Island Kingston Rhode Island USA
| | - Kerry L. LaPlante
- Infectious Diseases Research Program Providence Veterans Affairs Medical Center Providence Rhode Island USA
- College of Pharmacy University of Rhode Island Kingston Rhode Island USA
- Center of Innovation in Long‐Term Support Services Providence Veterans Affairs Medical Center Providence Rhode Island USA
- Warren Alpert Medical School of Brown University Providence Rhode Island USA
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Appaneal HJ, Lopes VV, LaPlante KL, Caffrey AR. Trends in Stenotrophomonas maltophilia antibiotic resistance rates in the United States Veterans Affairs Health System. J Med Microbiol 2022; 71. [DOI: 10.1099/jmm.0.001594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction.
Stenotrophomonas maltophilia
is an important multidrug-resistant Gram-negative pathogen. While largely a hospital-acquired pathogen, there have been increasing reports of the pathogen in the community.
Gap Statement. Trends in
S. maltophilia
prevalence and resistance rates that include outpatient isolates are unknown.
Aim. We described recent trends in prevalence and resistance of
S. maltophilia
in the national Veterans Affairs (VA) Healthcare system.
Methodology. The study identified positive
S. maltophilia
clinical cultures among VA adult patients from 2010 to 2018 across all VA hospitals, long-term care facilities/units, and outpatient settings. Annual
S. maltophilia
resistance rates were evaluated. Multidrug resistant (MDR) was defined as resistance to sulfamethoxazole/trimethoprim (SMX/TMP) and minocycline or levofloxacin. Time trends were assessed with regression analyses to estimate annual average percent changes (AAPC) with 95 % confidence intervals using Joinpoint software.
Results. Over the 9 year study period, 18 285
S
.
maltophilia
cultures were identified (57 % hospital, 3 % long-term care, 40 % outpatient). The most common source of
S. maltophilia
cultures were respiratory cultures (34.6 %) followed by urine cultures (30.4 %). In VA hospitals and long-term care facilities, the number of
S. maltophilia
cultures decreased significantly (by 5.4% and 8.4 % per year respectively). Overall, 3.1 % of isolates were MDR which remained stable over the study period. Resistance to other antibiotics assessed mostly remained stable, except SMX/TMP resistance decreased significantly by 8.5 % (2010, 15 %; 2018, 6 %) per year in VA hospitals.
Conclusion. While previous work has recognized
S. maltophilia
as primarily a nosocomial pathogen, the present study found that 40 % of cultures collected were among outpatients. Between 2010 and 2018, the number of positive
S. maltophilia
cultures decreased significantly in the national VA Healthcare System. Resistance to SMX/TMP decreased over the study period in VA hospitals and now more closely reflects previously reported resistance rates worldwide (0–10 %). MDR
S. maltophilia
remained stable and low in the national VA Healthcare System.
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Affiliation(s)
- Haley J. Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Vrishali V. Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Kerry L. LaPlante
- Warren Alpert Medical School of Brown University, Providence, RI
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Brown University School of Public Health, Providence, RI
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI, USA
| | - Aisling R. Caffrey
- Brown University School of Public Health, Providence, RI
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI, USA
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11
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Appaneal HJ, Caffrey AR, Lopes V, Piehl EC, Puzniak LA, LaPlante KL. Assessing Rates of Co-Resistance and Patient Outcomes in Multidrug-Resistant Pseudomonas aeruginosa. Microbiol Spectr 2022; 10:e0233622. [PMID: 36005836 PMCID: PMC9603501 DOI: 10.1128/spectrum.02336-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 08/04/2022] [Indexed: 01/04/2023] Open
Abstract
Multidrug-resistant (MDR) Pseudomonas aeruginosa infections are associated with poor patient outcomes due to complex co-resistance patterns. We described common co-resistance patterns, clinical characteristics, and associated outcomes in patients admitted with an MDR P. aeruginosa. This national, multicenter, retrospective cohort study within the Veterans Affairs included adults hospitalized with a MDR P. aeruginosa infection (January 2015-December 2020) per Centers for Disease Control definition. Clinical outcomes were compared among those with differing MDR P. aeruginosa co-resistance: resistant to carbapenems and extended-spectrum cephalosporins and piperacillin-tazobactam (CARB/ESC/PT) versus without CARB/ESC/PT resistance; resistant to carbapenems and extended-spectrum cephalosporins and fluoroquinolone (CARB/ESC/FQ) versus without CARB/ESC/FQ resistance. We included 3,763 hospitalized patients. Co-resistance to CARB/ESC/PT was observed in 42.7%, and to CARB/ESC/FQ in 40.7%. The lowest co-resistance rates were observed with ceftolozane-tazobactam (6.2%, n = 6/97; 12.5%, n = 10/80, respectively) and ceftazidime-avibactam (5.2%, n = 5/97; 12.5%, n = 10/80, respectively). Overall, 14.2% of patients died during hospitalization, 59.7% had an extended length of stay, and 14.9% had reinfection with hospitalization. Outcomes were similar between patients with MDR P. aeruginosa strains with and without co-resistance to CARB/ESC/PT and CARB/ESC/FQ. Among a national cohort of patients hospitalized with MDR P. aeruginosa infections, co-resistance to three classes of standard of care antibiotics, such as carbapenem, extended-spectrum cephalosporins, and piperacillin-tazobactam or fluoroquinolones, exceeded 40% in our study population, posing great concerns for selecting appropriate empirical therapy. Clinical outcomes were poor for all patients, regardless of different co-resistance patterns. New treatment options are needed for hospitalized patients with suspected or confirmed MDR P. aeruginosa infections. IMPORTANCE We studied antibiotic co-resistance patterns in a national group of hospitalized patients with infections due to multidrug-resistant (MDR) Pseudomonas aeruginosa, a type of bacteria that resists treatment to at least three classes of antibiotics. Co-resistance to antibiotic classes most typically used for treatment was common, which makes selecting appropriate antibiotics to successfully treat the infections difficult. Outcomes, including death, were poor for all patients in our study, regardless of the different patterns of co-resistance to common antibiotic classes. New antibiotics are needed to help treat hospitalized patients with MDR P. aeruginosa infections.
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Affiliation(s)
- Haley J. Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Aisling R. Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- School of Public Health, Brown University, Providence, Rhode Island, USA
| | - Vrishali Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
| | - Emily C. Piehl
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | | | - Kerry L. LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island, USA
- Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, Rhode Island, USA
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12
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Caffrey AR, Appaneal HJ, Liao JX, Piehl EC, Lopes V, Puzniak LA. Treatment Heterogeneity in Pseudomonas aeruginosa Pneumonia. Antibiotics (Basel) 2022; 11:antibiotics11081033. [PMID: 36009902 PMCID: PMC9405358 DOI: 10.3390/antibiotics11081033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 07/25/2022] [Accepted: 07/28/2022] [Indexed: 11/18/2022] Open
Abstract
We have previously identified substantial antibiotic treatment heterogeneity, even among organism-specific and site-specific infections with treatment guidelines. Therefore, we sought to quantify the extent of treatment heterogeneity among patients hospitalized with P. aeruginosa pneumonia in the national Veterans Affairs Healthcare System from Jan-2015 to Apr-2018. Daily antibiotic exposures were mapped from three days prior to culture collection until discharge. Heterogeneity was defined as unique patterns of antibiotic treatment (drug and duration) not shared by any other patient. Our study included 5300 patients, of whom 87.5% had unique patterns of antibiotic drug and duration. Among patients receiving any initial antibiotic/s with a change to at least one anti-pseudomonal antibiotic (n = 3530, 66.6%) heterogeneity was 97.2%, while heterogeneity was 91.5% in those changing from any initial antibiotic/s to only anti-pseudomonal antibiotics (n = 576, 10.9%). When assessing heterogeneity of anti-pseudomonal antibiotic classes, irrespective of other antibiotic/s received (n = 4542, 85.7%), 50.5% had unique patterns of antibiotic class and duration, with median time to first change of three days, and a median of two changes. Real-world evidence is needed to inform the development of treatment pathways and antibiotic stewardship initiatives based on clinical outcome data, which is currently lacking in the presence of such treatment heterogeneity.
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Affiliation(s)
- Aisling R. Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.)
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
- School of Public Health, Brown University, Providence, RI 02903, USA
- Correspondence:
| | - Haley J. Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.)
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
- School of Public Health, Brown University, Providence, RI 02903, USA
| | - J. Xin Liao
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.)
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Emily C. Piehl
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.)
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Vrishali Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.)
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Caffrey AR, Appaneal HJ, Liao JX, Piehl EC, Lopes V, Dillon RJ, Puzniak LA, LaPlante KL. The Comparative Effectiveness of Ceftolozane/Tazobactam versus Aminoglycoside- or Polymyxin-Based Regimens in Multi-Drug-Resistant Pseudomonas aeruginosa Infections. Antibiotics (Basel) 2022; 11:antibiotics11050626. [PMID: 35625270 PMCID: PMC9137796 DOI: 10.3390/antibiotics11050626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 05/02/2022] [Accepted: 05/03/2022] [Indexed: 11/16/2022] Open
Abstract
Pseudomonas aeruginosa infections are challenging to treat due to multi-drug resistance (MDR) and the complexity of the patients affected by these serious infections. As new antibiotic therapies come on the market, limited data exist about the effectiveness of such treatments in clinical practice. In this comparative effectiveness study of ceftolozane/tazobactam versus aminoglycoside- or polymyxin-based therapies among hospitalized patients with positive MDR P. aeruginosa cultures, we identified 57 patients treated with ceftolozane/tazobactam compared with 155 patients treated with aminoglycoside- or polymyxin-based regimens. Patients treated with ceftolozane/tazobactam were younger (mean age 67.5 vs. 71.1, p = 0.03) and had a higher comorbidity burden prior to hospitalization (median Charlson 5 vs. 3, p = 0.01) as well as higher rates of spinal cord injury (38.6% vs. 21.9%, p = 0.02) and P. aeruginosa-positive bone/joint cultures (12.3% vs. 0.7%, p < 0.0001). Inpatient mortality was significantly lower in the ceftolozane/tazobactam group compared with aminoglycosides or polymyxins (15.8% vs. 27.7%, adjusted odds ratio 0.39, 95% confidence interval 0.16−0.93). There were no significant differences observed for the other outcomes assessed. In hospitalized patients with MDR P. aeruginosa, inpatient mortality was 61% lower among patients treated with ceftolozane/tazobactam compared to those treated with aminoglycoside- or polymyxin-based regimens.
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Affiliation(s)
- Aisling R. Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.); (K.L.L.)
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
- School of Public Health, Brown University, Providence, RI 02903, USA
- Correspondence: ; Tel.: +1-401-874-5320
| | - Haley J. Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.); (K.L.L.)
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - J. Xin Liao
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.); (K.L.L.)
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Emily C. Piehl
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.); (K.L.L.)
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
| | - Vrishali Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.); (K.L.L.)
| | - Ryan J. Dillon
- Merck & Co., Inc., Rahway, NJ 07065, USA; (R.J.D.); (L.A.P.)
| | | | - Kerry L. LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA; (H.J.A.); (J.X.L.); (E.C.P.); (V.L.); (K.L.L.)
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI 02908, USA
- College of Pharmacy, University of Rhode Island, Kingston, RI 02881, USA
- Warren Alpert Medical School, Division of Infectious Diseases, Brown University, Providence, RI 02903, USA
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Appaneal HJ, O'Neill E, Lopes VV, LaPlante KL, Caffrey AR. National trends in hospital, long-term care and outpatient Acinetobacter baumannii resistance rates. J Med Microbiol 2021; 70. [PMID: 34919041 DOI: 10.1099/jmm.0.001473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Acinetobacter baumannii is a top-priority pathogen of the World Health Organization (WHO) and the Centers for Disease Control (CDC) due to antibiotic resistance.Gap Statement. Trends in A. baumannii resistance rates that include community isolates are unknown.Aim. Identify trends in A. baumannii resistance rates across the Veterans Affairs (VA) Healthcare System, including isolates from patients treated in hospitals, long-term care facilities and outpatient clinics nationally.Methodology. We included A. baumannii clinical cultures collected from VA patients from 2010 to 2018. Cultures were categorized by location: VA medical centers (VAMCs), long-term care (LTC) units [community living centers (CLCs)], or outpatient. We assessed carbapenem resistance, multidrug resistance (MDR) and extensive drug resistance (XDR). Time trends were assessed with Joinpoint regression.Results. We identified 19 376 A. baumannii cultures (53% VAMCs, 4% CLCs, 43% outpatient). Respiratory cultures were the most common source of carbapenem-resistant (43 %), multidrug-resistant (49 %) and extensively drug-resistant (21 %) isolates. Over the study period, the number of A. baumannii cultures decreased significantly in VAMCs (11.9% per year). In 2018, carbapenem resistance was seen in 28% of VAMC isolates and 36% of CLC isolates, but only 6% of outpatient isolates, while MDR was found in 31% of VAMC isolates and 36% of CLC isolates, but only 8 % of outpatient isolates. Carbapenem-resistant, multidrug-resistant and extensively drug-resistant A. baumannii isolates decreased significantly in VAMCs and outpatient clinics over time (VAMCs: by 4.9, 7.2 and 6.9%; outpatient: by 11.3, 10.5 and 10.2% per year). Resistant phenotypes remained stable in CLCs.Conclusion. In the VA nationally, the prevalence of A. baumannii is decreasing, as is resistance. Carbapenem-resistant and multidrug-resistant A. baumannii remain common in VAMCs and CLCs. The focus of infection control and antimicrobial stewardship efforts to prevent transmission of resistant A. baumannii should be in hospital and LTC settings.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Brown University School of Public Health, Providence, RI, USA
| | - Emily O'Neill
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Brown University School of Public Health, Providence, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Brown University School of Public Health, Providence, RI, USA
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15
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Xin Liao J, Lopes V, Appaneal HJ, LaPlante K, Caffrey A. 175. Antibiotic Resistance in Select Gram-negative Bacteria Over the Past Decade Among Hospitalized Veterans Nationally. Open Forum Infect Dis 2021. [DOI: 10.1093/ofid/ofab466.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Public health institutions including the World Health Organization and the United States Centers for Disease Control and Prevention (CDC) have recognized the threat of antibiotic resistant infections caused by Gram-negative bacteria. These bacteria are particularly concerning as they can demonstrate resistance to all available antibiotic classes through various mechanisms. We set out to assess antibiotic resistance trends in Gram-negative bacteria to optimize antimicrobial stewardship and infection control initiatives in our health system.
Methods
We identified positive cultures (1st per patient per month) of P. aeruginosa and select Enterobacterales (Citrobacter, Escherichia coli, Enterobacter, Klebsiella, Morganella morganii, Proteus mirabilis, Serratia marcescens) collected from patients hospitalized at Veterans Affairs (VA) Medical Centers nationally from 2011 to 2020. Time trends were assessed with joinpoint regression to estimate average annual percent changes (AAPC) with 95% confidence intervals (CIs) for the following resistance phenotypes utilizing CDC definitions: multi-drug resistance (MDR), extended-spectrum beta-lactamase (ESBL), and carbapenem (CR) and fluoroquinolone (FR) resistance.
Results
We included 496,384 isolates in our study: E. coli (32.6%), Klebsiella (20%), P. aeruginosa (18.9%), P. mirabilis (11.5%), Enterobacter (7.8%), Citrobacter (3.7%), S. marcescens (2.9%), and M. morganii (2.6%). Trends in resistance are shown in the figures. MDR, ESBL, CR, and FR decreased significantly (p< 0.05) over the study period for most of the organisms assessed, with the exception of MDR and ESBL E. coli and CR P. mirabilis which remained stable, and CR M. morganii which increased significantly by 7.1% per year (95% CI 0.2% to 14.5%). The largest decreases were in CR E. coli by 29.5% per year (95% CI -36.5% to -21.8%), CR Klebsiella by 23.7% per year (95% CI -27.6% to -19.5%), and MDR and CR S. marcescens by 12.2% (95% CI -14.4% to -9.9%) and 12.3% per year (95% CI -16.2% to -8.1%), respectively.
Figure 1. Antibiotic resistance trends in Citrobacter spp., E. coli, Enterobacter spp., and Klebsiella spp.
Antibiotic resistance trends (by percentage) in (a) Citrobacter spp, (b) E. coli, (c) Enterobacter spp, and (d) Klebsiella spp from 2011-2020. Abbreviations: MDR = multi-drug resistance (defined as non-susceptible to at least 1 drug in at least 3 of the following categories: extended-spectrum cephalosporins, fluoroquinolones, aminoglycosides, carbapenems, piperacillin/tazobactam); ESBL = extended spectrum beta-lactamase (defined as non-susceptible to at least 1 of the following drugs: cefepime, ceftriaxone, cefotaxime, ceftolozane/tazobactam, ceftazidime/avibactam); CR = carbapenem resistance (defined as non-susceptible to at least 1 carbapenem); FR = fluoroquinolone resistance (defined as non-susceptible to at least 1 fluoroquinolone); AAPC = annual average percentage change; CI = confidence interval.
Figure 2. Antibiotic resistance trends in Pseudomonas aeruginosa, Proteus mirabilis, Serratia marcescens, and Morganella morganii. Antibiotic resistance trends (by percentage) in (e) Pseudomonas aeruginosa, (f) Proteus mirabilis, (g) Serratia marcescens, and (h) Morganella morganii from 2011-2020. Abbreviations: MDR = multi-drug resistance (defined as non-susceptible to at least 1 drug in at least 3 of the following categories: extended-spectrum cephalosporins, fluoroquinolones, aminoglycosides, carbapenems, piperacillin/tazobactam); ESBL = extended spectrum beta-lactamase (defined as non-susceptible to at least 1 of the following drugs: cefepime, ceftriaxone, cefotaxime, ceftolozane/tazobactam, ceftazidime/avibactam); CR = carbapenem resistance (defined as non-susceptible to at least 1 carbapenem); FR = fluoroquinolone resistance (defined as non-susceptible to at least 1 fluoroquinolone); AAPC = annual average percentage change; CI = confidence interval.
Conclusion
Overall, MDR, ESBL, CR, and FR in Enterobacterales and P. aeruginosa decreased from 2011 to 2020 in the VA. These results may be related to the robust infection control and antimicrobial stewardship programs instituted among VA Medical Centers nationally.
Disclosures
Kerry LaPlante, PharmD, Merck (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc (Research Grant or Support) Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi, Inc (Research Grant or Support)
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Affiliation(s)
- J Xin Liao
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI
| | - Vrishali Lopes
- College of Pharmacy, University of Rhode Island, Kingston, RI, Providence, Rhode Island
| | - Haley J Appaneal
- Providence Veterans Affairs Medical Center, Providence, RI, United States
- School of Public Health, Brown University, Providence, RI, United States, Providence, Rhode Island
| | | | - Aisling Caffrey
- Rhode Island Infectious Diseases Research Program, Providence, RI
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Appaneal HJ, Shireman TI, Lopes VV, Mor V, Dosa DM, LaPlante KL, Caffrey AR. Poor clinical outcomes associated with suboptimal antibiotic treatment among older long-term care facility residents with urinary tract infection: a retrospective cohort study. BMC Geriatr 2021; 21:436. [PMID: 34301192 PMCID: PMC8299613 DOI: 10.1186/s12877-021-02378-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 06/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Antibiotic use is associated with several antibiotic-related harms in vulnerable, older long-term care (LTC) residents. Suboptimal antibiotic use may also be associated with harms but has not yet been investigated. The aim of this work was to compare rates of poor clinical outcomes among LTC residents with UTI receiving suboptimal versus optimal antibiotic treatment. METHODS We conducted a retrospective cohort study among residents with an incident urinary tract infection (UTI) treated in Veterans Affairs LTC units (2013-2018). Potentially suboptimal antibiotic treatment was defined as use of a suboptimal initial antibiotic drug choice, dose frequency, and/or excessive treatment duration. The primary outcome was time to a composite measure of poor clinical outcome, defined as UTI recurrence, acute care hospitalization/emergency department visit, adverse drug event, Clostridioides difficile infection (CDI), or death within 30 days of antibiotic discontinuation. Shared frailty Cox proportional hazard regression models were used to compare the time-to-event between suboptimal and optimal treatment. RESULTS Among 19,701 LTC residents with an incident UTI, 64.6% received potentially suboptimal antibiotic treatment and 35.4% experienced a poor clinical outcome. In adjusted analyses, potentially suboptimal antibiotic treatment was associated with a small increased hazard of poor clinical outcome (aHR 1.06, 95% CI 1.01-1.11) as compared with optimal treatment, driven by an increased hazard of CDI (aHR 1.94, 95% CI 1.54-2.44). CONCLUSION In this national cohort study, suboptimal antibiotic treatment was associated with a 6% increased risk of the composite measure of poor clinical outcomes, in particular, a 94% increased risk of CDI. Beyond the decision to use antibiotics, clinicians should also consider the potential harms of suboptimal treatment choices with regards to drug type, dose frequency, and duration used.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA. .,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA. .,College of Pharmacy, University of Rhode Island, Kingston, RI, USA. .,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA
| | - Vincent Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, 830 Chalkstone Ave, Providence, RI, 02908, USA.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA.,College of Pharmacy, University of Rhode Island, Kingston, RI, USA.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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Appaneal HJ, Caffrey AR, Lopes VV, Mor V, Dosa DM, LaPlante KL, Shireman TI. Predictors of potentially suboptimal treatment of urinary tract infections in long-term care facilities. J Hosp Infect 2021; 110:114-121. [PMID: 33549769 DOI: 10.1016/j.jhin.2021.01.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 01/15/2021] [Accepted: 01/15/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND Suboptimal antibiotic treatment of urinary tract infection (UTI) is high in long-term care facilities (LTCFs) and likely varies between facilities. Large-scale evaluations have not been conducted. AIM To identify facility-level predictors of potentially suboptimal treatment of UTI in Veterans Affairs (VA) LTCFs and to quantify variation across facilities. METHODS This was a retrospective cohort study of 21,938 residents in 120 VA LTCFs (2013-2018) known as Community Living Centers (CLCs). Potentially suboptimal treatment was assessed from drug choice, dose frequency, and/or treatment duration. To identify facility characteristics predictive of suboptimal UTI treatment, LTCFs with higher and lower rates of suboptimal treatment (≥median, < median) were compared using unconditional logistic regression models. Joinpoint regression models were used to quantify average percentage difference across facilities. Multilevel logistic regression models were used to quantify variation across facilities. FINDINGS The rate of potentially suboptimal antibiotic treatment varied from 1.7 to 34.2 per 10,000 bed-days across LTCFs. The average percentage difference in rates across facilities was 2.5% (95% confidence interval (CI): 2.4-2.7). The only facility characteristic predictive of suboptimal treatment was the incident rate of UTI per 10,000 bed-days (odds ratio: 4.9; 95% CI: 2.3-10.3). Multilevel models demonstrated that 94% of the variation between facilities was unexplained after controlling for resident and CLC characteristics. The median odds ratio for the full multilevel model was 1.37. CONCLUSION Potentially suboptimal UTI treatment was variable across VA LTCFs. However, most of the variation across LTCFs was unexplained. Future research should continue to investigate factors that are driving suboptimal antibiotic treatment in LTCFs.
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Affiliation(s)
- H J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA.
| | - A R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - V V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - V Mor
- Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - D M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
| | - K L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, USA; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, USA; College of Pharmacy, University of Rhode Island, Kingston, RI, USA; Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA; Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI, USA
| | - T I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI, USA
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Caffrey A, O’Neill ET, Appaneal HJ, Lopes V, LaPlante K. 847. Trends in S tenotrophomonas maltophilia Antibiotic Resistance Rates. Open Forum Infect Dis 2020. [PMCID: PMC7777195 DOI: 10.1093/ofid/ofaa439.1036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Studies from the 1990’s and 2000’s identified increasing rates of Stenotrophomonas maltophilia, particularly among respiratory isolates and in intensive care populations. Additionally, resistance in S. maltophilia was found to be worsening. We aimed to quantify recent trends in prevalence and resistance of S. maltophilia in the national Veterans Affairs (VA) Healthcare system.
Methods
We identified positive S. maltophilia clinical cultures among VA adult patients from 2010 to 2018, collected in either VA medical centers (VAMCs), community living centers (CLCs), or the outpatient (Outpt) setting. Multidrug resistance (MDR) was defined as resistance to sulfamethoxazole/trimethoprim (SMX/TMP) and minocycline or levofloxacin. Time trends were assessed with regression analyses to estimate annual average percent changes (AAPC) with 95% confidence intervals using Joinpoint Software.
Results
Over the 9-year study period, we identified 18,285 S. maltophilia cultures (57% VAMCs, 3% CLCs, 40% Outpt). S. maltophilia cultures made up 0.4% of all positive cultures in the VA. In VAMCs and CLCs, the number of S. maltophilia cultures decreased 5.1% and 8.5% per year, respectively. Alternatively, of all positive cultures in VAMCs, the proportion that were S. maltophilia increased significantly by 2.6% per year.
SMX/TMP resistance decreased significantly by 8.5% (2010, 15%; 2018, 6%) per year in VAMCs, and decreased non-significantly by 8.7% (2010, 13%, 2018, 6%) per year in CLCs and 6.0% (2010, 12%; 2018, 7%) in the outpatient setting. No other significant changes in resistance were observed over the study period. MDR increased non-significantly by 1.2% per year.
Conclusion
While previous studies found increasing rates of S. maltophilia, the number of positive S. maltophilia cultures decreased in the national VA Healthcare System between 2010 and 2018. However, S. maltophilia is making up a greater proportion of positive culture over time. During the study period, resistance to SMX/TMP decreased and now more closely reflects previously reported resistance rates worldwide (0-10%).
Disclosures
Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi (Research Grant or Support) Haley J. Appaneal, Pharm.D, Shionogi, Inc. (Research Grant or Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)
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Affiliation(s)
- Aisling Caffrey
- Rhode Island Infectious Diseases Research Program, Providence, RI
| | - Emily T O’Neill
- 1. Providence Veterans Affairs Medical Center, Providence, RI, United States 2. College of Pharmacy, University of Rhode Island, Kingston, RI, United States, Providence, Rhode Island
| | - Haley J Appaneal
- 1. Providence Veterans Affairs Medical Center, Providence, RI, United States 2. College of Pharmacy, University of Rhode Island, Kingston, RI, United States 3. School of Public Health, Brown University, Providence, RI, United States, Providence, Rhode Island
| | | | - Kerry LaPlante
- Rhode Island Infectious Diseases Research Program, Providence, RI
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Caffrey A, Appaneal HJ, Lopes V, LaPlante K. 1610. Epidemiology and Treatment Heterogeneity in A cinetobacter baumanii Infections. Open Forum Infect Dis 2020. [PMCID: PMC7778191 DOI: 10.1093/ofid/ofaa439.1790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Acinetobacter baumannii is known as a highly resistant organism causing serious infections in intensive care populations. However, the epidemiology of infections caused by Acinetobacter baumannii and approaches to treatment are not well described in a national healthcare system.
Methods
Our retrospective cohort study included patients with positive Acinetobacter baumannii cultures collected from any source during hospitalizations at Veterans Affairs (VA) medical centers nationally from January 2010 to April 2019. We evaluated patient characteristics and utilized exposure mapping to identify treatment patterns, including treatment heterogeneity. Heterogeneity was defined as patterns of antibiotic treatment (drug and duration) not shared by any other patient.
Results
Our study included 7,551 admissions with positive Acinetobacter baumannii cultures. The mean age was 66.7 years (±12.1) and 97.4% were male. Most patients were admitted from other healthcare facilities (59.2%) and 20.8% were in intensive care during the admission. Most patients had their culture collected on the day after admission and the median time to culture completion was 4 days (interquartile range 3-5). Acinetobacter baumannii cultures were most commonly obtained from urine (33.6%), followed by skin and soft tissue (25.3%), lung (21.8%), blood (9.2%), and bone/joint (5.0%). The median length of hospital stay was 11 days, with inpatient mortality and 30-day mortality rates of 11.6% and 12.5%, respectively.
Treatment heterogeneity was high, with 88.5% of admissions having different antibiotic treatment patterns (drug and duration), with a median time to first change of 1 day and median of 3 changes. Only 2% of the admissions were treated with polymyxins and 3.0% with colistin. Carbapenems were used in 18.9% of the admissions and extended-spectrum cephalosporins in 31.7% of the admissions.
Conclusion
In VA hospitals, Acinetobacter baumannii infections are observed in both critical and non-critical patient populations, mostly among patients with healthcare exposures. Acinetobacter baumannii infections were found to have various sources of infection, mostly from urine and skin and soft tissue, and approaches to treatment were highly varied.
Disclosures
Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi (Research Grant or Support) Haley J. Appaneal, PharmD, Shionogi, Inc. (Research Grant or Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)
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Affiliation(s)
- Aisling Caffrey
- Rhode Island Infectious Diseases Research Program, Providence, RI
| | - Haley J Appaneal
- 1. Providence Veterans Affairs Medical Center, Providence, RI, United States 2. College of Pharmacy, University of Rhode Island, Kingston, RI, United States 3. School of Public Health, Brown University, Providence, RI, United States, Providence, Rhode Island
| | | | - Kerry LaPlante
- Rhode Island Infectious Diseases Research Program, Providence, RI
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Caffrey A, O’Neill ET, Appaneal HJ, Lopes V, LaPlante K. 846. Trends in A cinetobacter baumanii Antibiotic Resistance Rates. Open Forum Infect Dis 2020. [PMCID: PMC7776211 DOI: 10.1093/ofid/ofaa439.1035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background Carbapenem-resistant Acinetobacter baumannii is described as an urgent threat by the Centers for Disease Control and Prevention and several older studies have indicated increasing resistance in Acinetobacter. We sought to describe these trends in the national Veterans Affairs (VA) Healthcare System. Methods We assessed A. baumannii positive clinical cultures collected from VA patients (> 18 years) from 2010 to 2018. We categorized cultures based on location at the time of collection: VA medical center (VAMC), community living center (CLC), or outpatient (Outpt). Multidrug resistance (MDR) and extensive drug resistance (XDR) were defined as resistance to > 1 drug in > 3 or all of the following categories, respectively: extended-spectrum cephalosporins (es-CS), fluoroquinolones (FQ), aminoglycosides (AMG), carbapenems (CARB), piperacillin/tazobactam (PIP/TAZ), and ampicillin/sulbactam (AMP/SUL). Joinpoint Software was used for regression analyses of trends over time and to estimate annual average percent changes (AAPC) with 95% confidence intervals. Results We identified 19,376 A. baumannii positive cultures over the study period (53% VAMCs, 4% CLCs, 43% Outpts), which represented 0.5% of all positive cultures in the VA. In VAMCs, the number of A. baumannii cultures decreased significantly by 12.5% per year. Of all positive cultures in VAMCs, the proportion that were A. baumannii decreased significantly by 5.4% per year. Similar trends were observed in CLCs, while Outpt cultures remained stable. Over the 9-year study period, resistance decreased significantly, with MDR decreasing by 10.2% per year and XDR decreasing by 9.4%. Carbapenem resistance decreased significantly by 4.9% per year in VAMCs (2010, 39%; 2018 28%) and 11.3% in Outpts (2010, 12%; 2018, 6%). Similar annual significant decreases were observed with AMG (9.4%), es-CS (1.4%), and FQ (7.4%) in VAMCs; es-CS (2.7%) and FQ (5.6%) in CLCs; and AMG (9.5%) and FQ (8.2%) in Outpts. Conclusion In the national VA Healthcare System, the prevalence of A. baumannii is decreasing, as is the resistance previously observed with this organism. MDR A. baumannii still made up one-third of cultures in VAMCs and CLCs in 2018, and thus remains a treatment challenge. Disclosures Aisling Caffrey, PhD, Merck (Research Grant or Support)Pfizer (Research Grant or Support)Shionogi (Research Grant or Support) Haley J. Appaneal, Pharm.D, Shionogi, Inc. (Research Grant or Support) Kerry LaPlante, PharmD, Merck (Advisor or Review Panel member, Research Grant or Support)Ocean Spray Cranberries, Inc. (Research Grant or Support)Pfizer Pharmaceuticals (Research Grant or Support)Shionogi, Inc. (Research Grant or Support)
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Affiliation(s)
- Aisling Caffrey
- Rhode Island Infectious Diseases Research Program, Providence, RI
| | - Emily T O’Neill
- 1. Providence Veterans Affairs Medical Center, Providence, RI, United States 2. College of Pharmacy, University of Rhode Island, Kingston, RI, United States, Providence, Rhode Island
| | - Haley J Appaneal
- 1. Providence Veterans Affairs Medical Center, Providence, RI, United States 2. College of Pharmacy, University of Rhode Island, Kingston, RI, United States 3. School of Public Health, Brown University, Providence, RI, United States, Providence, Rhode Island
| | | | - Kerry LaPlante
- Rhode Island Infectious Diseases Research Program, Providence, RI
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Appaneal HJ, Caffrey AR, LaPlante KL. What Is the Role for Metronidazole in the Treatment of Clostridium difficile Infection? Results From a National Cohort Study of Veterans With Initial Mild Disease. Clin Infect Dis 2020; 69:1288-1295. [PMID: 30561531 DOI: 10.1093/cid/ciy1077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 12/12/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Metronidazole may still be an appropriate therapeutic option for mild Clostridium difficile infection (CDI) in select patients, but data are limited to guide clinicians in identifying these patients. METHODS Our 2-stage study included a national cohort of Veterans with a first episode of mild CDI (2010-2014). First, among those treated with metronidazole, we identified predictors of success, defined as absence of all-cause mortality or recurrence 30 days posttreatment, using multivariable unconditional logistic regression. Second, among a subgroup of patients with characteristics predictive of success identified in the first stage, we compared clinical outcomes among those treated with metronidazole compared with vancomycin, using Cox proportional hazards models for time to 30-day all-cause mortality, CDI recurrence, and failure. RESULTS Among 3656 patients treated with metronidazole, we identified 3282 patients with success and 374 patients without success (failure). Younger age was the only independent predictor of success. Age ≤65 years was associated with an odds of success 1.63 times higher (95% confidence interval [CI], 1.29-2.06) than age >65 years. Among 115 propensity score-matched pairs ≤65 years of age, no significant differences were observed between metronidazole and vancomycin (reference) for all-cause mortality (hazard ratio [HR], 0.29 [95% CI, .06-1.38]), CDI recurrence (HR, 0.62 [95% CI, .26-1.49]), or failure (HR, 0.50 [95% CI, .23-1.07]). CONCLUSIONS Among patients ≤65 years of age with initial mild CDI, clinical outcomes were similar with metronidazole and vancomycin. These data suggest that metronidazole may be considered for the treatment of initial mild CDI among patients 65 years of age or younger.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Kingston.,College of Pharmacy, University of Rhode Island, Kingston.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Kingston.,College of Pharmacy, University of Rhode Island, Kingston.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Brown University School of Public Health, Providence, Rhode Island
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Kingston.,College of Pharmacy, University of Rhode Island, Kingston.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Division of Infectious Diseases, Warren Alpert Medical School, Brown University, Providence, Rhode Island
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Appaneal HJ, Caffrey AR, Lopes VV, Dosa DM, Shireman TI, LaPlante KL. Frequency and Predictors of Suboptimal Prescribing Among a Cohort of Older Male Residents with Urinary Tract Infection. Clin Infect Dis 2020; 73:e2763-e2772. [PMID: 32590839 DOI: 10.1093/cid/ciaa874] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Unnecessary antibiotic treatment of suspected urinary tract infection (UTI) is common in long-term care facilities (LTCFs). However, less is known about the extent of suboptimal treatment, in terms of antibiotic choice, dose, and duration, after the decision to use antibiotics has been made. METHODS We described the frequency of potentially suboptimal treatment among residents with an incident UTI (first during the study with none in the year prior) in Veterans Affairs' (VA) Community Living Centers (CLCs, 2013-2018). Time trends were analyzed using Joinpoint regression. Residents with UTIs receiving potentially suboptimal treatment were compared to those receiving optimal treatment to identify resident characteristics predictive of suboptimal antibiotic treatment, using multivariable unconditional logistic regression models. RESULTS We identified 21,938 residents with an incident UTI treated in 120 VA CLCs, of which 96.0% were male. Potentially suboptimal antibiotic treatment was identified in 65.0% of residents and decreased 1.8% annually (p<0.05). Potentially suboptimal initial drug choice was identified in 45.6% of residents, suboptimal dose frequency in 28.6%, and longer than recommended duration in 12.7%. Predictors of suboptimal antibiotic treatment included: prior fluoroquinolone exposure (adjusted odds ratio [aOR] 1.38), chronic renal disease (aOR 1.19), age >85 years (aOR 1.17), prior skin infection (aOR 1.14), recent high white blood cell count (aOR 1.08), and genitourinary disorder (aOR 1.08). CONCLUSION Similar to findings in non-VA facilities, potentially suboptimal treatment was common but improving in CLC residents with an incident UTI. Predictors of suboptimal antibiotic treatment should be targeted with antibiotic stewardship interventions to improve UTI treatment.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Theresa I Shireman
- Center for Gerontology & Health Care Research and Department of Health Services Policy & Practice, Brown University School of Public Health, Providence, RI
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, United States.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI, United States.,College of Pharmacy, University of Rhode Island, Kingston, RI.,Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI
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Appaneal HJ, Caffrey AR, Beganovic M, Avramovic S, LaPlante KL. Predictors of Clostridioides difficile recurrence across a national cohort of veterans in outpatient, acute, and long-term care settings. Am J Health Syst Pharm 2019; 76:581-590. [PMID: 31361830 DOI: 10.1093/ajhp/zxz032] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE The greatest challenge in treating Clostridioides difficile infection (CDI) is disease recurrence, which occurs in about 20% of patients, usually within 30 days of treatment cessation. We sought to identify independent predictors of first recurrence among a national cohort of veterans with CDI. METHODS We conducted a case-control study among acute and long-term care Veterans Affairs (VA) inpatients and outpatients with a first CDI episode (positive stool sample for C. difficile toxin[s] and receipt of at least 2 days of CDI treatment) between 2010 and 2014. Cases experienced first recurrence within 30 days from the end of treatment. Controls were those without first recurrence matched 4:1 to cases on year, facility, and severity. Multivariable conditional logistic regression was used to identify predictors of first recurrence. RESULTS We identified 32 predictors of first recurrence among 974 cases and 3,896 matched controls. Significant predictors included medication use prior to (probiotics, fluoroquinolones, laxatives, third- or fourth-generation cephalosporins), during (first- or second-generation cephalosporins, penicillin/amoxicillin/ampicillin, third- and fourth-generation cephalosporins), and after CDI treatment (probiotics, any antibiotic, proton pump inhibitors [PPIs], and immunosuppressants). Other predictors included current biliary tract disease, malaise/fatigue, cellulitis/abscess, solid organ cancer, medical history of HIV, multiple myeloma, abdominal pain, and ulcerative colitis. CONCLUSION In a large national cohort of outpatient and acute and long-term care inpatients, treatment with certain antibiotics, PPIs, immunosuppressants, and underlying disease were among the most important risk factors for first CDI recurrence.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Aisling R Caffrey
- Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Maya Beganovic
- Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Sanja Avramovic
- Health Administration and Policy, George Mason University, Fairfax, VA
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI, and College of Pharmacy, University of Rhode Island, Kingston, RI
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Hughes MSA, Dosa DM, Caffrey AR, Appaneal HJ, Jump RLP, Lopes V, LaPlante KL. Antibiograms Cannot Be Used Interchangeably Between Acute Care Medical Centers and Affiliated Nursing Homes. J Am Med Dir Assoc 2019; 21:72-77. [PMID: 31537479 DOI: 10.1016/j.jamda.2019.07.016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 07/16/2019] [Accepted: 07/17/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To determine whether antibiograms for Veterans Affairs (VA) nursing homes (NHs), termed Community Living Centers, are similar to those from their affiliated acute care medical centers. DESIGN Descriptive study. SETTING AND PARTICIPANTS We compared the 2017 antibiograms for VA NHs to their affiliated VA medical centers (VAMCs). Antibiograms included antibiotic susceptibility rates for commonly observed bacteria in this setting (Staphylococcus aureus, Enterococcus spp, Escherichia coli, Klebsiella spp, Proteus mirabilis, and Pseudomonas aeruginosa). METHODS Antibiograms were considered to be in complete agreement when the overall susceptibility rate between the NH and affiliated VAMC was either at or above 80% or below 80% across all bacteria and antibiotics. Average percentage of bacteria-antibiotic comparisons in disagreement per facility pair, and number of facilities with agreement for specific bacteria-antibiotic comparisons were also assessed. The chi-square test was used to compare disagreement between NH-VAMC facilities based on geographic proximity of the NH to the VAMC, culture source, and bed size. RESULTS A total of 119 NH-VAMC affiliate pairs were included in this analysis, with 71% (84/119) on the same campus and 29% (35/119) on geographically distinct campuses. None of the NH-VAMC pairs demonstrated complete agreement (all bacteria vs all antibiotics) between their antibiograms. On average, 20% of the bacteria-antibiotic comparisons from the antibiogram disagreed clinically per NH-VAMC pair, and almost twice as often the nursing home had lower susceptibility (higher resistance) than the acute care facility. Some bacteria-antibiotic comparisons agreed in all facilities (eg, E coli-imipenem; S aureus-linezolid; S aureus-vancomycin), while others showed greater disagreement (eg, Klebsiella spp-cefazolin; Klebsiella spp-ampicillin-sulbactam; P aeruginosa-ciprofloxacin). Rates of clinical disagreement were similar by geographic proximity of the NH to the VAMC, culture source, and bed size. CONCLUSIONS AND IMPLICATIONS Overall, this study showed a moderate lack of agreement between VA NH antibiograms and their affiliate VAMC antibiograms. Our data suggest that antibiograms of acute care facilities are often not accurate approximations of the nursing home resistance patterns and therefore should be used with caution (if at all) in guiding empiric antibiotic therapy.
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Affiliation(s)
- Maria-Stephanie A Hughes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; School of Public Health, Brown University, Providence, RI
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; School of Public Health, Brown University, Providence, RI
| | - Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; School of Public Health, Brown University, Providence, RI
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) and the Specialty Care Center of Innovation, Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, OH
| | - Vrishali Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation for Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI.
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Appaneal HJ, Caffrey AR, Hughes MSA, Lopes VV, Jump RLP, LaPlante KL, Dosa DM. Trends in Collection of Microbiological Cultures Across Veterans Affairs Community Living Centers in the United States Over 8 Years. J Am Med Dir Assoc 2019; 21:115-120. [PMID: 31466935 DOI: 10.1016/j.jamda.2019.07.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Revised: 06/27/2019] [Accepted: 07/02/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVES To describe and evaluate changes in the collection of microbiological cultures across Veterans Affairs (VA) Community Living Centers (CLCs) nationally. DESIGN Descriptive study. SETTING 146 VA CLCs. PARTICIPANTS We identified both positive and negative microbiological cultures collected during VA CLC admissions from January 2010 through December 2017. MEASURES We measured the average annual percentage change (AAPC) in the rate of cultures collected per 1000 bed days and per admission, overall and stratified by culture type (ie, urine, blood, skin and soft tissue, and respiratory tract). AAPCs were also calculated for the proportion and rate of positive cultures collected, overall and stratified by culture type and organism (ie, Escherichia coli, Proteus mirabilis, Staphylococcus aureus, Enterococcus spp, Pseudomonas aeruginosa, Klebsiella spp, Enterobacter spp, Morganella morganii, Citrobacter spp, Serratia marcescens, and Streptococcus pneumoniae). Joinpoint regression software was used to assess trends and estimate AAPCs and 95% confidence intervals (CIs). RESULTS Over 8 years, 355,329 cultures were collected. The rate of cultures collected per 1000 bed days of care decreased significantly by 6.0% per year (95% CI -8.7%, -3.2%). The proportion of positive cultures decreased by 0.9% (95% CI -1.4%, -0.4%). The most common culture types were urine (48.4%), followed by blood (27.7%). The rate of cultures collected per 1000 bed days of care decreased per year by 6.3% for urine, 5.0% for blood, 4.4% for skin and soft tissue, and 4.9% for respiratory tract. In 2010, S aureus was the most common organism identified, and in all subsequent years E coli was the most common. CONCLUSION AND IMPLICATIONS We identified a significant reduction in the number of cultures collected over time among VA CLCs. Our findings may be explained by decreases in the collection of unnecessary cultures in VA CLCs nationally due to increased antibiotic stewardship efforts targeting unnecessary culturing and antibiotic treatment.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Brown University School of Public Health, Providence, RI
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Brown University School of Public Health, Providence, RI
| | - Maria-Stephanie A Hughes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI
| | - Vrishali V Lopes
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI
| | - Robin L P Jump
- Geriatric Research Education and Clinical Center (GRECC) and the Specialty Care Center of Innovation at the Louis Stokes Cleveland Department of Veterans Affairs Medical Center, Cleveland, OH; Division of Infectious Diseases and HIV Medicine, Department of Medicine and Department of Population & Quantitative Health Sciences, Case Western Reserve University School of Medicine, Cleveland, OH
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Warren Alpert Medical School of Brown University, Providence, RI
| | - David M Dosa
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, RI; Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, RI; College of Pharmacy, University of Rhode Island, Kingston, RI; Brown University School of Public Health, Providence, RI; Warren Alpert Medical School of Brown University, Providence, RI.
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Appaneal HJ, Caffrey AR, Beganovic M, Avramovic S, LaPlante KL. Predictors of Mortality Among a National Cohort of Veterans With Recurrent Clostridium difficile Infection. Open Forum Infect Dis 2018; 5:ofy175. [PMID: 30327788 DOI: 10.1093/ofid/ofy175] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 07/17/2018] [Indexed: 12/13/2022] Open
Abstract
Background Though recurrent Clostridium difficile infection (CDI) is common and poses a major clinical concern, data are lacking regarding mortality among patients who survive their initial CDI and have subsequent recurrences. Risk factors for mortality in patients with recurrent CDI are largely unknown. Methods Veterans Affairs patients with a first CDI (stool sample with positive C. difficile toxin(s) and ≥2 days CDI treatment) were included (2010-2014). Subsequent recurrences were defined as additional CDI episodes ≥14 days after the stool test date and within 30 days of the end of treatment. A matched (1:4) case-control analysis was conducted using multivariable conditional logistic regression to identify predictors of all-cause mortality within 30 days of the first recurrence. Results Crude 30-day all-cause mortality rates were 10.6% for the initial CDI episode, 8.3% for the first recurrence, 4.2% for the second recurrence, and 5.9% for the third recurrence. Among 110 cases and 440 controls, 6 predictors of mortality were identified: use of proton pump inhibitors (PPIs; odds ratio [OR], 3.86; 95% confidence interval [CI], 2.14-6.96), any antibiotic (OR, 3.33; 95% CI, 1.79-6.17), respiratory failure (OR, 8.26; 95% CI, 1.71-39.92), congitive dysfunction (OR, 2.41; 95% CI, 1.02-5.72), nutrition deficiency (OR, 2.91; 95% CI, 1.37-6.21), and age (OR, 1.04; 95% CI, 1.01-1.07). Conclusions In our national cohort of Veterans, crude mortality decreased by 44% from the initial episode to the third recurrence. Treatment with antibiotics, use of PPIs, and underlying comorbidities were important predictors of mortality in recurrent CDI. Our study assists health care providers in identifying patients at high risk of death after CDI recurrence.
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Affiliation(s)
- Haley J Appaneal
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,College of Pharmacy, University of Rhode Island, Kingston, Rhode Island.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island
| | - Aisling R Caffrey
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,College of Pharmacy, University of Rhode Island, Kingston, Rhode Island.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Brown University School of Public Health, Providence, Rhode Island
| | - Maya Beganovic
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,College of Pharmacy, University of Rhode Island, Kingston, Rhode Island
| | - Sanja Avramovic
- Health Administration and Policy, George Mason University, Fairfax, Virginia
| | - Kerry L LaPlante
- Infectious Diseases Research Program, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,College of Pharmacy, University of Rhode Island, Kingston, Rhode Island.,Center of Innovation in Long-Term Support Services, Providence Veterans Affairs Medical Center, Providence, Rhode Island.,Division of Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Appaneal HJ, Luther MK, Timbrook TT, LaPlante KL, Dosa DM. Facilitators and Barriers to Antibiotic Stewardship: A Qualitative Study of Pharmacists' Perspectives. Hosp Pharm 2018; 54:250-258. [PMID: 31320775 DOI: 10.1177/0018578718781916] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: The Veterans Affairs (VA) is a leader in the implementation and advancement of antibiotic stewardship programs throughout the nation. The Centers for Disease Control and Prevention (CDC) has also led national antibiotic stewardship efforts and has outlined core elements to improve antibiotic use in hospitals, long-term care, and outpatient settings. Many facilities still face challenges to the implementation and maintenance of successful programs, particularly in nonacute care settings. The objective of this study was to identify barriers and facilitators to antibiotic stewardship within the VA medical centers through qualitative interviews with pharmacists. Methods: Eight semi-structured telephone interviews were conducted with pharmacists from 6 VA medical centers within VA New England Healthcare System. Pharmacist respondents were either pharmacy champions (for medical centers with established programs) or pharmacists with responsibilities in making antibiotic recommendations (locations without established programs). All interviews were audio recorded and transcribed verbatim. NVivo 8 was used for data coding and analysis. Results: Pharmacists from all 8 medical centers were contacted for interviews and pharmacists from 6 medical centers agreed to interviews (75% VA New England medical center participation). Three main themes regarding antibiotic stewardship were identified from the interviews with pharmacists. Respondents described the importance of (1) a supportive organizational culture, (2) protected time for antibiotic stewardship, and (3) a cohesive organizational structure in the success of antibiotic stewardship programs. Conclusions: Our findings support the CDC core elements for antibiotic stewardship, in particular the importance of leadership commitment in the creation of a culture that supports antibiotic stewardship and in ensuring staff are given sufficient time for antibiotic stewardship efforts. Although a strong supportive culture has been built, strategies focused on fostering increased protected time for antibiotic stewardship and a cohesive organizational structure may be helpful in advancing and sustaining successful antibiotic stewardship programs that improve patient outcomes.
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Affiliation(s)
- Haley J Appaneal
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Megan K Luther
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Tristan T Timbrook
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA
| | - Kerry L LaPlante
- Veterans Affairs Medical Center, Providence, RI, USA.,University of Rhode Island, Kingston, RI, USA.,Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - David M Dosa
- Veterans Affairs Medical Center, Providence, RI, USA.,Brown University School of Public Health, Providence, RI, USA
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Appaneal HJ, Caffrey AR, Jiang L, Dosa D, Mermel LA, LaPlante KL. Antibiotic resistance rates for Pseudomonas aeruginosa clinical respiratory and bloodstream isolates among the Veterans Affairs Healthcare System from 2009 to 2013. Diagn Microbiol Infect Dis 2017; 90:311-315. [PMID: 29310949 DOI: 10.1016/j.diagmicrobio.2017.11.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 11/30/2022]
Abstract
Pseudomonas aeruginosa is a major cause of healthcare-associated infections and resistance among isolates is an increasing burden. The study purpose was to describe national resistance rates for clinical P. aeruginosa respiratory and bloodstream cultures and the prevalence of multidrug-resistant (MDR) P. aeruginosa within the Veterans Affairs (VA). MDR was defined as non-susceptibility to at least one drug in at least 3 of the following 5 categories: carbapenems, extended-spectrum cephalosporins, aminoglycosides, and piperacillin/tazobactam. We reviewed 24,562 P. aeruginosa respiratory and bloodstream isolates across 126 VA facilities between 2009 and 2013. Most isolates were collected from inpatient settings (82%). Resistance was highest in fluoroquinolones (33%) and exceeded 20% for all classes assessed (carbapenems, extended-spectrum cephalosporins, aminoglycosides, and piperacillin/tazobactam). Resistance was higher in inpatient settings and in respiratory isolates. Prevalence of MDR was 20% overall (22% for inpatient isolates, 11% outpatient, 21% respiratory, 17% bloodstream). Our findings are consistent with previous surveillance reports.
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Affiliation(s)
- Haley J Appaneal
- Veterans Affairs Medical Center, Rhode Island Infectious Diseases Research Program, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; Veterans Affairs Medical Center, Center of Innovation in Long Term Services and Supports, Providence, RI.
| | - Aisling R Caffrey
- Veterans Affairs Medical Center, Rhode Island Infectious Diseases Research Program, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; Veterans Affairs Medical Center, Center of Innovation in Long Term Services and Supports, Providence, RI; Brown University School of Public Health, Providence, RI
| | - Lan Jiang
- Veterans Affairs Medical Center, Center of Innovation in Long Term Services and Supports, Providence, RI
| | - David Dosa
- Veterans Affairs Medical Center, Center of Innovation in Long Term Services and Supports, Providence, RI; Center for Gerontology and HealthCare Research, Brown University School of Public Health, Providence, RI
| | - Leonard A Mermel
- University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; Department of Epidemiology and Infection Control, Rhode Island Hospital, Providence, RI; Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI
| | - Kerry L LaPlante
- Veterans Affairs Medical Center, Rhode Island Infectious Diseases Research Program, Providence, RI; University of Rhode Island, Department of Pharmacy Practice, College of Pharmacy, Kingston, RI; Veterans Affairs Medical Center, Center of Innovation in Long Term Services and Supports, Providence, RI; Warren Alpert Medical School of Brown University, Division of Infectious Diseases, Providence, RI
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Appaneal HJ, Jiang L, Dosa DM, LaPlante KL. Antibiotic Prescribing Pathway for Urinary Tract Infections: A “Low-Hanging Fruit” Antibiotic Stewardship Target in Nursing Homes. J Am Geriatr Soc 2017; 65:2744-2745. [DOI: 10.1111/jgs.15083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Haley J. Appaneal
- Infectious Diseases Research Program; Veterans Affairs Medical Center; Providence Rhode Island
- Department of Pharmacy Practice; College of Pharmacy; University of Rhode Island; Kingston Rhode Island
- Veterans Affairs Medical Center; Center of Innovation in Long Term Services and Supports; Providence Rhode Island
| | - Lan Jiang
- Veterans Affairs Medical Center; Center of Innovation in Long Term Services and Supports; Providence Rhode Island
| | - David M. Dosa
- Veterans Affairs Medical Center; Center of Innovation in Long Term Services and Supports; Providence Rhode Island
- Center for Gerontology and HealthCare Research; School of Public Health; Brown University; Providence Rhode Island
| | - Kerry L. LaPlante
- Infectious Diseases Research Program; Veterans Affairs Medical Center; Providence Rhode Island
- Department of Pharmacy Practice; College of Pharmacy; University of Rhode Island; Kingston Rhode Island
- Veterans Affairs Medical Center; Center of Innovation in Long Term Services and Supports; Providence Rhode Island
- Division of Infectious Diseases; Warren Alpert Medical School; Brown University; Providence Rhode Island
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