Antimicrobial management in community acquired pneumonia in hospital at home: Is there room for improvement?

INTRODUCTION: Community Acquired Pneumonia (CAP) is common disease that can be treated in Hospital At Home (HAH). In this paper we evaluate the room of improvement in the use of antibiotics in CAP in HH. METHODS: Patients with CAP were retrospectively recruited in two Spanish hospitals from 1/1/18 to 10/30/19. Demographic, clinical and quality of antibiotic prescription variables were recorded. Subsequently, we created a new variable that collected six quality of care indicator, categorizing and comparing patients into two groups: good quality of care (4 or more indicators performed) or poor quality of care (3 or less indicators performed). RESULTS: We recruited 260 patients. The request for diagnostic tests and the adequacy to Clinical Practice Guidelines were 85.4% and 85.8% respectively. Percentages of de-escalation (53.7%) and sequential therapy (57.7%) when indicated were low. The average length of treatment was 7.3 days for intravenous and 9.5 days for total. Quality of prescription was good in 134 (63.2%) patients, being more frequent in those who were admitted directly to HAD from the emergency room. It was also associated with less readmission at 30 days. CONCLUSION: There is a wide room for improvement in some fields of antimicrobials use in HAH that could stimulate the implementation of Antimicrobial Stewardship Programs.

Manejo de la enfermedad tromboembólica venosa en la hospitalización a domicilio: ¿Qué pacientes atendemos y cuál es su perfil de riesgo? / Management of Venous Trhomboembolic Disease in Home Hospitalization: Which Patients Do We Treat and What Is Their Risk Stratification?

Introducción: Las Guías de Práctica Clínica re-cogen el mejor manejo de la Enfermedad Trom-boembólica Venosa (ETEV) en función de la estratificación del riesgo en cuanto a ingreso o tratamiento ambulatoria. La utilidad de la Hos-pitalización a Domicilio (HAD) en esta enferme-dad es poco conocida. Métodos: Realizamos un estudio descriptivo y comparativo de todos los pacientes admitidos en HAD por ETEV durante dos años, empareján-dolos con otro grupo de pacientes de hospitali-zación convencional (HC). Analizamos también el destino de los pacientes (HAD o HC) en fun-ción de la estratificación del riesgo. Resultados: Obtuvimos una muestra de n=76 pacientes. La estancia hospitalaria fue menor en el grupo de HAD. No hubo diferencias esta-dísticamente significativas en el resto de varia-bles. El 22,9% de los pacientes con riesgo bajo de mortalidad ingresaron. Conclusión: La estratificación del riesgo o las características clínicas de los pacientes con ETEV no tuvieron relevancia frente a la elec-ción del destino en régimen de HAD, pudien-do haber primado más los criterios generales de ingreso en HAD (preferencias del paciente, soporte domiciliario adecuado, o el manejo de otras comorbilidades).(AU)

Introduction: Clincal Practice Guidelines show the best management of Venous Thromboem-bolic Disease (VTE) based on risk stratification in terms of admission or outpatient treatment. The utility of Home Hospitalization (HH) in this disease is poorly understood. Methods: We conducted a descriptive and com-parative study of all patients admitted at HH for VTE for two years, matching them with another group of conventional hospitalization (CH) pa-tients. We also analyzed the destination of the patients (HH or CH) based on their risk strati-fication. Results: We obtained a sample of n=76 pa-tients. The hospital length of stay was shorter in the HAD group. There were no statistically sig-nificant differences in the rest of the variables. 22.9% of patients with low risk of mortality were admitted at CH or HH. Conclusion: Risk stratification or clinical charac-teristics of patients with VTE were not relevant when it came to the choice of destination under the HH regimen. General criteria for admission to HH (patient preferences, adequate home support, or management other comorbidities) may have prevailed more in order to take that decision.(AU)

Efectos adversos neuropsiquiátricos de dolutegravir en la práctica clínica real / Neuropsychiatric adverse effects of dolutegravir in real-life clinical practice

Introducción: Los inhibidores de la integrasa, y especialmente dolutegravir (DTG), son el tratamiento de primera línea antirretroviral por su eficacia y seguridad. Aunque en los ensayos pivotales la tasa de efectos adversos (EA) era baja (2-3%), en los estudios de vida real parece ser mayor, especialmente los EA neuropsiquiátricos. El objetivo fue determinar el porcentaje de EA e interrupción de DTG en nuestro centro y la relación con los antecedentes psiquiátricos. Métodos: Estudio descriptivo retrospectivo de pacientes que iniciaron DTG entre 2015-2017. Se registraron: interrupción del tratamiento, EA y enfermedad psiquiátrica. Se realizó seguimiento desde el inicio del del tratamiento con DTG y se registraron las hospitalizaciones y las visitas a urgencias y atención primaria. Fue autorizado por el Comité Ético de Investigación Clínica de Aragón. Resultados: Se incluyeron 283 pacientes, entre 11-87 años, 70% varones. El 21% naive. Interrumpieron el tratamiento con DTG el 24%, un 10% por EA. Se detectó un 5% de EA neuropsiquiátricos. Este grupo tenía más antecedentes psiquiátricos (62 vs. 41%; p=0,002) que el de pacientes que continuaron el tratamiento, y precisaron más visitas en atención primaria (18,8 vs. 8,4%; p=0,016) y urgencias (8,7 vs. 3,3%; p=0,061). Conclusión: Los pacientes que interrumpieron el tratamiento con DTG tenían más antecedentes psiquiátricos. Por ello, aunque se precisan más estudios, sería necesario valorar este antecedente previamente al tratamiento con inhibidores de la integrasa. Síntomas como ansiedad, insomnio o depresión pueden ser EA de DTG con una frecuencia mayor de la esperada. Ser identificados por los médicos de atención primaria y urgencias podría evitar una cascada de prescripción innecesaria.(AU)

Introduction: Integrase inhibitors and especially dolutegravir (DTG) are placed as a first-line antiretroviral treatment for their efficacy and safety. Although in the pivotal trials the rate of adverse effects (AEs) was low (2-3%), in real-life studies it appears to be higher, especially neuropsychiatric AEs. The objective is to determine the percentage of AEs and discontinuation of DTG in our site and the relationship with the psychiatric background. Methods: Retrospective descriptive study of patients starting DTG from 2015 to 2017. Discontinuation of treatment, AEs and previous psychiatric pathology were recorded. Follow-up is carried out since the beginning of the treatment, and hospitalizations and emergency room and primary care visits were registered. The study was authorized by the Ethics Committee for Clinical Research of Aragon. Results: Two hundred and eighty-three patients were included, between 11 and 87 years old, 70% male. 21% were naive. 24% of the patients discontinued treatment with DTG, 10% due to AEs. Neuropsychiatric AEs were detected in 5%. This group of patients had a more frequent previous psychiatric history (62 vs. 41%; P=.002) than the ongoing treatment group and they needed more visits to primary care (18.8 vs. 8.4%; P=.016) and emergency room (8,7 vs. 3.3%; P=.061). Conclusion: Patients who discontinued treatment with DTG had more psychiatric history. Although more studies are required, it is necessary to assess this background before starting treatment with integrase inhibitors. Symptoms such as anxiety, insomnia or depression can be DTG AEs more frequently than expected. Being identified by primary care and emergency physicians could avoid the unnecessary prescription of other medications.(AU)

Neuropsychiatric adverse effects of dolutegravir in real-life clinical practice. / Efectos adversos neuropsiquiátricos de dolutegravir en la práctica clínica real.

INTRODUCTION: Integrase inhibitors and especially dolutegravir (DTG) are placed as a first-line antiretroviral treatment for their efficacy and safety. Although in the pivotal trials the rate of adverse effects (AEs) was low (2-3%), in real-life studies it appears to be higher, especially neuropsychiatric AEs. The objective is to determine the percentage of AEs and discontinuation of DTG in our site and the relationship with the psychiatric background. METHODS: Retrospective descriptive study of patients starting DTG from 2015 to 2017. Discontinuation of treatment, AEs and previous psychiatric pathology were recorded. Follow-up is carried out since the beginning of the treatment, and hospitalizations and emergency room and primary care visits were registered. The study was authorized by the Ethics Committee for Clinical Research of Aragon. RESULTS: Two hundred and eighty-three patients were included, between 11 and 87 years old, 70% male. 21% were naive. 24% of the patients discontinued treatment with DTG, 10% due to AEs. Neuropsychiatric AEs were detected in 5%. This group of patients had a more frequent previous psychiatric history (62 vs. 41%; P=.002) than the ongoing treatment group and they needed more visits to primary care (18.8 vs. 8.4%; P=.016) and emergency room (8,7 vs. 3.3%; P=.061). CONCLUSION: Patients who discontinued treatment with DTG had more psychiatric history. Although more studies are required, it is necessary to assess this background before starting treatment with integrase inhibitors. Symptoms such as anxiety, insomnia or depression can be DTG AEs more frequently than expected. Being identified by primary care and emergency physicians could avoid the unnecessary prescription of other medications.