An evaluation of dental antibiotic prescribing practices in the United States

BACKGROUND

Antibiotic prescribing practices among general dentists and dental specialists in the United States remains poorly understood. The purpose of this study was to compare prescribing practices across dental specialties, evaluate the duration of antibiotics dentists prescribed, and determine variation in antibiotic selection among dentists.

METHODS

The authors performed a retrospective cross-sectional analysis of dental care provider specialties linked to deidentified antibiotic claims data from a large pharmacy benefits manager during the 2015 calendar year.

RESULTS

As a group, general dentists and dental specialists were responsible for more than 2.9 million antibiotic prescriptions, higher than levels for several other medical and allied health care provider specialties. Antibiotic treatment duration generally was prolonged and commonly included broad-spectrum agents, such as amoxicillin clavulanate and clindamycin. Although amoxicillin was the most commonly prescribed antibiotic among all dental specialties, there was substantial variation among other antibiotics each specialty selected. The most common antibiotic treatment durations were 7 and 10 days.

CONCLUSIONS

This study's results demonstrate that dentists frequently prescribe antibiotics for prolonged periods and often use broad-spectrum antibiotics. Further studies are necessary to evaluate the appropriateness of these antibiotic prescribing patterns.

PRACTICAL IMPLICATIONS

The clinically significant variation in antibiotic selection and treatment duration identified among all dental specialties in this study population implies that further research and guidance into the treatment of dental infections is necessary to improve and standardize antibiotic prescribing practices.

The effectiveness of treatment supporter interventions in antiretroviral treatment adherence in sub-Saharan Africa: a systematic review and meta-Analysis

This systematic review and meta-analysis evaluated the effectiveness of treatment supporter interventions (TSI) in improving ART adherence and viral suppression among adults living with HIV (PLWH) in sub-Saharan Africa. This review included ten randomized controlled trials (RCT) and six cohort studies comparing treatment support interventions to the standard of care (SOC). Primary outcomes include pill count ART adherence and viral load suppression (VLS). Pooled relative risk ratios (PRR) with 95% confidence intervals were generated using random-effects models. Stratified analyses and meta-regressions were conducted to determine the effect of study type, follow-upperiod, and patient treatment supporters on ART adherence. Treatment supporters included partners, friends, family members, trained community health workers, and HIV positive peers. TSIs were associated with a 7.6% higher ART adherence compared to the SOC group (PRR = 1.076, [95% CI = 1.005, 1.151]). VLS was 5% higher in the treatment group compared to the SOC group (PRR = 1.05, [95% CI = 1.061, 1.207]). There was a significant, positive association between TSIs and VLS in community-based delivery settings but not in facility-based settings. TSIs were statistically significant for VLS in cohort study designs (RR = 1.073, [95% CI = 1.028, 1.121]) but not in RCTs. Findings suggest that TSIs critical in facilitating optimal ART adherence and VLS among PLWHs.

COVID-19 Outcomes and Genomic Characterization of SARS-CoV-2 Isolated From Veterans in New England States: Retrospective Analysis

BACKGROUND

Clinical and virologic characteristics of COVID-19 infections in veterans in New England have not been described. The average US veteran is a male older than the general US population. SARS-CoV-2 infection is known to cause poorer outcomes among men and older adults, making the veteran population an especially vulnerable group for COVID-19.

OBJECTIVE

This study aims to evaluate clinical and virologic factors impacting COVID-19 outcomes.

METHODS

This retrospective chart review included 476 veterans in six New England states with confirmed SARS-CoV-2 infection between April and September 2020. Whole genome sequencing was performed on SARS-CoV-2 RNA isolated from these veterans, and the correlation of genomic data to clinical outcomes was evaluated. Clinical and demographic variables were collected by manual chart review and were correlated to the end points of peak disease severity (based on oxygenation requirements), hospitalization, and mortality using multivariate regression analyses.

RESULTS

Of 476 veterans, 274 had complete and accessible charts. Of the 274 veterans, 92.7% (n=254) were men and 83.2% (n=228) were White, and the mean age was 63 years. In the multivariate regression, significant predictors of hospitalization (C statistic 0.75) were age (odds ratio [OR] 1.05, 95% CI 1.03-1.08) and non-White race (OR 2.39, 95% CI 1.13-5.01). Peak severity (C statistic 0.70) also varied by age (OR 1.07, 95% CI 1.03-1.11) and O2 requirement on admission (OR 45.7, 95% CI 18.79-111). Mortality (C statistic 0.87) was predicted by age (OR 1.06, 95% CI 1.01-1.11), dementia (OR 3.44, 95% CI 1.07-11.1), and O2 requirement on admission (OR 6.74, 95% CI 1.74-26.1). Most (291/299, 97.3%) of our samples were dominated by the spike protein D614G substitution and were from SARS-CoV-2 B.1 lineage or one of 37 different B.1 sublineages, with none representing more than 8.7% (26/299) of the cases.

CONCLUSIONS

In a cohort of veterans from the six New England states with a mean age of 63 years and a high comorbidity burden, age was the largest predictor of hospitalization, peak disease severity, and mortality. Non-White veterans were more likely to be hospitalized, and patients who required oxygen on admission were more likely to have severe disease and higher rates of mortality. Multiple SARS-CoV-2 lineages were distributed in patients in New England early in the COVID-19 era, mostly related to viruses from New York State with D614G mutation.

Antimicrobial resistance in patients with haematological malignancies: a scoping review

Antimicrobial resistance (AMR) is a substantial global health threat. Patients with haematological malignancies have an increased risk of AMR infection due to disease-related and treatment-related immunosuppression. This scoping review searched four bibliographic databases from Jan 1, 2000, to Dec 7, 2023, for publications on AMR bacterial infections in patients with haematological malignancies and identified 274 eligible articles. AMR prevalence data extraction focused on WHO bacterial priority pathogens. The prevalence of AMR bacterial infections from seven WHO priority pathogens in patients with haematological malignancies was 35% (95% CI 30-40; I2 99·4%). The most frequent AMR infections reported were bloodstream infections, with the highest reported AMR pathogens in third-generation cephalosporin-resistant Enterobacterales (pooled prevalence rate 44% [95% CI 23-64; I2 99·8%]), meticillin-resistant Staphylococcus aureus (43% [31-54; I2 95·9%]), and vancomycin-resistant enterococci (41% [26-56; I2 96·2%]). 53 (65%) of the 81 studies that reported mortality showed higher mortality rates associated with AMR infections. 168 (61%) studies were conducted in high-income countries, with no studies published from the WHO Africa region, revealing a substantial data gap from low-income and middle-income regions. Future efforts should prioritise standardised reporting measures, robust surveillance, antimicrobial stewardship, and well designed clinical trials, particularly in under-represented regions, to mitigate the effect of AMR on cancer care.

Extensive Brainstem Posterior Reversible Encephalopathy Syndrome in a Hemodialysis Non-Adherent Patient

Posterior reversible encephalopathy syndrome (PRES) refers to a disorder of reversible vasogenic edema caused by rapid hyperperfusion of the brain that classically involves areas supplied by the posterior circulation such as the parieto-occipital region. It may present with atypical features such as brainstem and spinal cord involvement. Common causes include renal failure, pre-eclampsia/eclampsia among pregnant women, rapid changes in systemic blood pressure, and autoimmune diseases. The most prevalent presenting signs and symptoms are encephalopathy, seizures and headache. A 64-year-old female presented to a dialysis unit after missing several sessions with twitching in her extremities and elevated blood pressure. Additionally, she recently terminated clonidine use and was likely experiencing rebound hypertension. The continuous electroencephalogram (EEG) demonstrated generalized, non-convulsive seizures. MRI findings were notable for hyperintensities in the pons, middle cerebellar peduncles, cerebellar hemispheres, and periventricular and subcortical matter with medulla and proximal spinal cord involvement. A notable clinical sequela of PRES in this patient was coma. Aggressive blood pressure control led to significant improvement and return to her neurologic baseline. PRES can present with extensive brainstem involvement with a clinical sequela of coma. Multiple underlying causes such as dialysis non-adherence and rebound hypertension following clonidine discontinuation contributed to the development of this condition in this patient.

2513. The Effect of Treatment Supporter Interventions on ART Adherence in Eastern and Southern Africa: a systematic review and meta-analysis

Background

Access to ART has significantly reduced morbidity and mortality and improved quality of life in people living with HIV (PLWH). Treatment supporter interventions (TSIs) utilize patient or facility selected individuals to increase optimal ART adherence through home visits, peer support and medication management. This aim of this meta-analysis is to evaluate the effectiveness of TSIs in improving optimal ART adherence among PLWH in SSA using process- and outcome-oriented measures.

Methods

We searched PubMed, EMBASE, SCOPUS, Web of Science (WOS), Cochrane Library, and ClinicalTrials.gov for randomized controlled trials or cohort studies comparing treatment supporter interventions to the standard of care conducted in Eastern and Southern Africa. The primary outcomes were ART adherence measured by pill counts and virologic suppression. Pooled risk ratios with 95% confidence intervals were calculated using random-effects models. Stratified analyses and meta-regression were conducted to determine the effect of study type and patient nomination of treatment supporters on ART adherence.

Results

Sixteen studies, 10 RCTs and 6 cohort studies, were selected for inclusion. Virologic suppression was reported in 14 studies with 12,457 individuals in TSIs and 23,592 receiving the standard of care. Optimal ART adherence was reported in 7 RCTs only (2,185 individuals in TSI and 1,545 receiving SOC). Optimal ART adherence was 7.6% higher in TSIs compared with SOC (pooled RR 1.076, 95% CI 1.005–1.151, p = 0.035). Heterogeneity of these studies was high (I² = 91.1%). Virologic suppression was 5% higher in TSIs compared with the standard of care (pooled RR 1.05, 95% CI 1.019–1.081, P = 0.001). Meta-regression demonstrated that virologic suppression did not significantly vary by study type (b = −0.042, 95% CI −0.09–0.001, P = 0.057) and patient selection of the treatment supporter (b = 0.026, 95% CI −0.07–0.12, P = 0.554).

Conclusion

Optimal ART adherence is marginally higher in treatment supporter interventions compared with the standard of care. Patient-nominated supporters achieve similar rates of virologic suppression to facility-selected supporters, and could play a critical role in addressing disparities in health outcomes among PLWH.

Disclosures

All authors: No reported disclosures.