Reducing Fluoroquinolone Use and Clostridioides difficile Infections in Community Nursing Homes Through Hospital-Nursing Home Collaboration.

OBJECTIVE: Nursing homes (NHs) are an important target for antibiotic stewardship (AS). We describe a collaborative model to reduce Clostridioides difficile infections (CDIs) in NHs through optimization of antibiotic use including a reduction in high-risk antibiotics such as fluoroquinolones. DESIGN: Quasi-experimental, pre- and post-intervention study. SETTING AND PARTICIPANTS: Six NHs in Monroe County, NY. METHODS: A hospital-based AS expert team assisted NHs in identifying targets for improving antibiotic use. Interventions included (1) collaboration with a medical director advisory group to develop NH consensus guidelines for testing and treatment of 2 syndromes (urinary tract infections and pneumonia) for which fluoroquinolone use is common, (2) provision of multifaceted NH staff education on these guidelines and education of residents and family members on the judicious use of antibiotics, and (3) sharing facility-specific and comparative antibiotic and CDI data. We used Poisson regression to estimate antibiotic use per 1000 resident days (RD) and CDIs per 10,000 RD, pre- and post-intervention. Segmented regression analysis was used to estimate changes in fluoroquinolone and total antibiotic rates over time. RESULTS: Postintervention, the monthly rate of fluoroquinolone days of therapy (DOT) per 1000 RD significantly decreased by 39% [rate ratio (RR) 0.61, 95% confidence interval (CI) 0.59-0.62, P < .001] across all NHs and the total antibiotic DOT decreased by 9% (RR 0.91, 95% CI 0.90-0.92, P < .001). Interrupted time series analysis of fluoroquinolone and total DOT rates confirmed these changes. The quarterly CDI rate decreased by 18% (RR 0.82, 95% CI 0.68-0.99, P = .042). CONCLUSIONS AND IMPLICATIONS: A hospital-NH partnership with a medical director advisory group achieved a significant reduction in total antibiotic and fluoroquinolone use and contributed to a reduction in CDI incidence. This approach offers one way for NHs to gain access to AS expertise and resources and to standardize practices within the local community.

Mechanical ventilation of patients hospitalized in medical wards vs the intensive care unit--an observational, comparative study.

BACKGROUND: In some hospitals, patients are mechanically ventilated on the wards in addition to the intensive care unit (ICU) because of the shortage of ICU beds. OBJECTIVE: The aim of the study was to compare the outcome and ventilatory management of medical patients mechanically ventilated on the medical wards and in the ICU. DESIGN: This was a prospective, observational, noninterventional study over a 6-month period. SETTING: The study was conducted in internal medicine wards and the ICU of a 500-bed community university-affiliated hospital. PATIENTS: Ninety-nine mechanically ventilated medical patients in the ICU or on the medical wards because of shortage of ICU beds were included in the study. RESULTS: Baseline characteristics of the patients ventilated in the ICU (group 1) and in the medical wards (group 2) were collected. Thirty-four patients were ventilated in the ICU and 65 in the wards during the study period. In-hospital survival rate in group 1 was 38% vs 20% in group 2 (P < .05). The Acute Physiologic and Chronic Health Evaluation (APACHE) II score in group 1 was 24 +/- 7 vs 27 +/- 7 in group 2 (P < .05). Other prognostic factors were similar. The age of the survivors in the 2 groups was similar: 57 +/- 25 years in group 1 vs 69 +/- 13 years in group 2 (P = NS). Mean number of ventilatory changes in group 1 was 7.5 +/- 1.4 per day per patient, whereas it was 1.3 +/- 1.0 in group 2 (P < .001). The number of arterial blood gas analyses in group 1 was 7.7 +/- 1.2 per day per patient compared with 2.3 +/- 1.3 in group 2 (P < .001). Twenty percent (20%) of the patients in group 1 had endotracheal tube-related inadvertent events compared with 62% of the patients in group 2 (P < .05). CONCLUSIONS: We conclude that in medical patients requiring mechanical ventilation, there is a higher in-hospital survival rate in ICU-ventilated patients as compared with ventilated patients managed on the medical wards. In addition, ICU provides a better monitoring associated with less endotracheal tube-related complications and more active ventilatory management.

Possible cocaine-induced acute renal failure without rhabdomyolysis.

Cocaine-induced acute renal failure has been reported in association with rhabdomyolysis. We describe a case of a young African American male who developed acute renal failure, which possibly occurred after inhalation of cocaine without concomitant rhabdomyolysis. His renal function recovered with supportive hydration. The most likely mechanism was intense vasoconstriction. Clinicians need to be mindful of this unique feature of cocaine intoxication.