Identifying racial disparities in the management of heart failure with reduced ejection fraction.

OBJECTIVE(S): Heart failure (HF) is chronic and progressive. Individuals with a left ventricular ejection fraction (LVEF or EF) < 40% are classified as having heart failure with reduced ejection fraction (HFrEF). Black patients have the highest incidence of HF and are more likely to suffer serious consequences from the disease. Identifying and addressing racial disparities in care is vital to ensuring health equity. The primary objective was to determine the association of race with 1-year heart HF admission rates for white and black patients, when adjusted for EF and age. The secondary objective was to determine the proportion of patients not on guideline-directed medication therapy (GDMT). DESIGN: This study was a retrospective chart review conducted between 10/22/2021 and 11/22/2022 of Veteran patients with HFrEF who were identified via the VA Heart Failure Dashboard. Only White and Black patients were included. A multivariable logistic regression was used to determine odds of admission due to HF. Pharmacotherapy was analyzed to identify gaps in GDMT and if racial disparities existed. SETTING AND PARTICIPANTS: Veterans within the Veterans Affairs Western New York Healthcare System. OUTCOME MEASURES: One-year HF admission rates for white and black patients, when adjusted for EF and age. Proportion of patients not on GDMT. RESULTS: Of the 345 patients with HF originally identified, 172 were included; 22% were admitted within one year. Black patients were 2.9 times more likely to be admitted. (P = 0.031). A median of two drugs (interquartile range [IQR] 1-3) could be added and one dose could be optimized (IQR 1-4) to reach GDMT goals. No differences were found in the prescribing of GDMT or in proportion of patients not on GDMT at recommended doses between white and black patients. CONCLUSION: Black patients were more likely to be admitted for HF than white patients. Pharmacists can play an important role in identifying the need for optimizing GDMT. Future studies could focus on pharmacist-led prospective interventions with an aim to close the gap in racial disparities.

Impact of Penicillin Allergy on Time to First Dose of Antimicrobial Therapy and Clinical Outcomes.

PURPOSE: The objective of this study was to evaluate the impact of a listed penicillin allergy on the time to first dose of antibiotic in a Veterans Affairs hospital. Additional clinical outcomes of patients with penicillin allergies were compared with those of patients without a penicillin allergy. METHODS: A retrospective chart review of veterans admitted through the emergency department with a diagnosis of pneumonia, urinary tract infection, bacteremia, and sepsis from January 2006 to December 2015 was conducted. The primary outcome was time to first dose of antibiotic treatment, defined as the time from when the patient presented to the emergency department to the medication administration time. Secondary outcomes included total antibiotic therapy duration and treatment outcomes, including mortality, length of stay, and 30-day readmission rate. FINDINGS: A total of 403 patients were included in the final analysis; 57 patients (14.1%) had a listed penicillin allergy. The average age of the population was 75 years and 99% of the population was male. The mean time to first dose of antibiotic treatment for patients with a penicillin allergy was prolonged compared with those without a penicillin allergy (236.1 vs 186.6 minutes; P = 0.03), resulting in an approximately 50-minute delay. Penicillin-allergic patients were more likely to receive a carbapenem or fluoroquinolone antibiotic (P < 0.0001). IMPLICATIONS: Patients with a penicillin allergy had a prolonged time to first dose of antibiotic therapy. No significant differences were found in total antibiotic duration, length of stay, or 30-day readmission rate. The small sample size, older population, and single-center nature of this study may limit the generalizability of the present findings to other populations.

Successful treatment of multidrug-resistant Pseudomonas aeruginosa pubic symphysis osteomyelitis with ceftolozane/tazobactam.

New antibiotic options are needed for the treatment of multidrug-resistant (MDR) Pseudomonas infections. We present a case of a man aged 64 years with a bladder fistula due to radiation, ultimately causing osteomyelitis of the pubic symphysis. Repeated antibiotic courses, without correcting the fistula, resulted in infection with MDR Pseudomonas aeruginosa. He was successfully treated for his osteomyelitis through cystectomy, aggressive debridement and a prolonged course of antimicrobials directed at the MDR Pseudomonas isolate.

Obesity and Heart Failure as Predictors of Failure in Outpatient Skin and Soft Tissue Infections.

The purpose of this study was to evaluate risk factors for failure of antibiotic treatment within 30 days for uncomplicated skin infections of outpatients treated in a Veterans Affairs hospital. A retrospective chart review of outpatients between January 2006 and July 2015 with an ICD-9 (International Statistical Classification of Diseases and Related Health Problems) code of cellulitis or abscess was included in the analysis. The primary outcome was success versus failure of the antibiotic, with failure defined as another antibiotic prescribed or hospitalization within 30 days for the original indication. A total of 293 patients were included in the final analysis, 24% of whom failed within 30 days. Obesity/overweight (body mass index [BMI] of >25 kg/m2) was identified in 83% of the overall population, with 16% of that population having a BMI greater than 40 kg/m2 An elevated mean BMI of 34.2 kg/m2 (P = 0.0098) was found in the subset of patients who failed oral antibiotics compared to a BMI of 31.32 kg/m2 in patients who were treated successfully. Additionally, the patients who failed had an increased prevalence of heart failure at 16% (P = 0.027). Using multivariate logistic regression, BMI and heart failure were determined to be significant predictors of antibiotic prescription failure. Each 10-kg/m2 unit increase in BMI was associated with a 1.62-fold-greater odds of failure. A diagnosis of heart failure increased the odds of failure by 2.6-fold (range, 1.1- to 5.8-fold). Outpatients with uncomplicated skin infections with an elevated BMI and heart failure were found to have increased odds of failure, defined as hospitalization or additional antibiotics within 30 days.

Review of Safety and Efficacy of Sleep Medicines in Older Adults.

PURPOSE: Insomnia is problematic for older adults. After behavioral modifications fail to show adequate response, pharmacologic options are used. The pharmacokinetics of agents used to treat insomnia may be altered. This review focuses on the safety and efficacy of medications used to treat insomnia. METHODS: A literature search of Medline, PubMed, and Embase was conducted (January 1966-June 2016). It included systematic reviews, randomized controlled trials, observational studies, and case series that had an emphasis on insomnia in an older population. Search terms included medications approved by the US Food and Drug Administration for insomnia: benzodiazepines (triazolam, estazolam, temazepam, flurazepam, and quazepam), nonbenzodiazepine receptor agonists (non-BzRAs; zaleplon, zolpidem, and eszopiclone), suvorexant, ramelteon, doxepin and trazodone. Off-label drugs such as other antidepressants, antihistamines, antipsychotics, gabapentin, pramipexole, tiagabine, valerian, and melatonin were also included. FINDINGS: Cognitive behavioral therapy and sleep hygiene are considered initial therapy for insomnia. Benzodiazepines are discouraged in the geriatric population, especially for long-term use. Although non-BzRAs have improved safety profiles compared with benzodiazepines, their side effects include dementia, serious injury, and fractures, which should limit their use. Ramelteon has a minimal adverse effect profile and is effective for sleep-onset latency and increased total sleep time, making it a valuable first-line option. Although the data on suvorexant are limited, this drug improves sleep maintenance and has mild adverse effects, including somnolence; residual daytime sedation has been reported, however. Sedating low-dose antidepressants should only be used for insomnia when the patient has comorbid depression. Antipsychotic agents, pramipexole, and tiagabine have all been used for insomnia, but none has been extensively studied in an older population, and all have considerable adverse effects. Gabapentin may be useful in patients with restless leg syndrome or chronic neuropathic pain and insomnia. Diphenhydramine should be avoided in the elderly. Valerian and melatonin are unregulated products that have a small impact on sleep latency and can produce residual sedation. IMPLICATIONS: An ideal treatment for insomnia should help to improve sleep latency and sleep duration with limited awakenings and be without significant adverse effects such as daytime somnolence or decreased alertness. Cognitive behavioral therapy should always be first line treatment. Clinical inertia regarding previous prominent use of benzodiazepines and non-BzRAs will be a significant challenge for patients accustomed to their issuance. The future direction of insomnia treatment should have an emphasis on nonpharmacologic interventions, treating comorbid conditions, and focusing therapy on using benzodiazepines and non-BzRAs as last resorts.

Evidence of a clinically significant interaction between warfarin and intravesical gemcitabine.

PURPOSE: A case of supratherapeutic International Normalized Ratio (INR) values and hematomas subsequent to concomitant administration of warfarin and intravesical gemcitabine is reported. SUMMARY: A 90-year-old man with bladder cancer refractory to bacillius Calmette-Guérin was diagnosed with deep vein thrombosis (DVT) and started on warfarin one month before starting treatment with intravesical gemcitabine 2 g (one dose per week for six weeks). Before intravesical gemcitabine was started, the patient reached consecutive therapeutic INR values. During the first five cycles of intravesical gemcitabine, the patient began to experience critically elevated INRs, which resulted in hospitalization and led to the discovery of hematomas. At hospital discharge, the decision was made to discontinue warfarin permanently given the patient's history of critically elevated INRs. Instead, enoxaparin was initiated due to the patient's history of DVT and active malignancy. Enoxaparin was started at a therapeutic, renally adjusted dosage of 60 mg subcutaneously once daily after the patient's hematomas resolved and hemoglobin level stabilized. The patient was cleared for discharge to his home after 17 days of hospitalization. He was scheduled to follow up with both urology and hematology departments regarding any further treatment for bladder cancer. A week after discharge, the patient's family decided that he would not receive the last (sixth) cycle of intravesical gemcitabine. To our knowledge, this is the first reported case of an interaction between intravesical gemcitabine and warfarin. CONCLUSION: A 90-year-old man on a stable dose of warfarin experienced an increase in INR values after receiving intravesical gemcitabine for the treatment of bladder cancer.

Male veterans with complicated urinary tract infections: Influence of a patient-centered antimicrobial stewardship program.

BACKGROUND: The influence of antimicrobial stewardship programs (ASPs) on outcomes in male veterans treated for complicated urinary tract infection has not been determined. METHODS: This was a retrospective cohort study encompassing the study period January 1, 2005-October 31, 2014, which was conducted at a 150-bed Veterans Affairs Healthcare System facility in Buffalo, NY. Male veterans admitted for treatment of complicated urinary tract infection were identified using ICD-9-CM codes. Outcomes before and after implementation of a patient-centered ASP, including duration of antibiotic therapy, length of hospitalization, readmission within 30 days, and Clostridium difficile infection were compared. Interventions resulting from the ASP were categorized. RESULTS: Of the 1,268 patients screened, 241 met criteria for inclusion in the study (n = 118 and n = 123 in the pre-ASP and ASP group, respectively). Duration of antibiotic therapy was significantly shorter in the ASP group (10.32 days vs 11.96 days; P < .0001), as was length of hospitalization (5.76 days vs 6.76 days; P = .015). There was no difference in 30-day readmission. A total of 170 interventions were identified that resulted from the ASP (1.39 interventions per patient). CONCLUSIONS: ASPs may be useful to improve clinical outcomes in men with complicated urinary tract infection. Implementation of an ASP was associated with significant decreases in duration of antibiotic therapy and length of hospitalization, without adversely affecting 30-day readmission rates.

Impact of Antimicrobial Stewardship on Outcomes in Hospitalized Veterans With Pneumonia.

PURPOSE: The purpose of this study was to evaluate the impact of an antimicrobial stewardship program (ASP) on outcomes for inpatients with pneumonia, including length of stay, treatment duration, and 30-day readmission rates. METHODS: A retrospective chart review comparing outcomes of veterans admitted with pneumonia before (2005-2006) and after (2013-2014) implementation of an ASP was conducted; pneumonia was defined according to International Classification of Diseases, Ninth Revision (ICD-9) codes. Infectious diseases physicians and pharmacist in the ASP provided appropriate recommendations to the primary medicine teams. Bivariate analysis of baseline characteristics and comorbid conditions were performed between the time frames. Least squares regression was used to analyze length of stay, time of IV to PO conversions, and duration of antibiotics. Multivariate logistic regressions were used to determine odds of 30-day readmission and odds of Clostridium difficile infections between time periods. FINDINGS: There were 86 patients in the pre-ASP period and 88 patients in the ASP period. Mean length of stay decreased from 8.1 to 6.6 days (P = 0.02), total duration of antibiotic therapy decreased from 12 to 8.5 days (P < 0.0001), and time of IV to PO antibiotic conversions decreased from 5.3 to 3.9 days (P = 0.0003), before ASP and during ASP, respectively. The odds ratio of 30-day readmission before ASP was 2.78 and 0.36 during the ASP (P = 0.05). The odds ratios of Clostridium difficile infections before ASP was 2.08 and 0.48 during the ASP (P = 0.37). IMPLICATIONS: The ASP interventions were associated with shorter durations of therapy, shorter lengths of stay, and lower rates of readmission and Clostridium difficile infections within 30 days. Limitations of this study are retrospective cohort design, small study population, limited study population diversity, and non-concurrent cohort times periods.