Carbapenemase production among less-common Enterobacterales genera: 10 US sites, 2018.

BACKGROUND: Historically, United States' carbapenem-resistant Enterobacterales (CRE) surveillance and mechanism testing focused on three genera: Escherichia, Klebsiella, and Enterobacter (EsKE); however, other genera can harbour mobile carbapenemases associated with CRE spread. OBJECTIVES: From January through May 2018, we conducted a 10 state evaluation to assess the contribution of less common genera (LCG) to carbapenemase-producing (CP) CRE. METHODS: State public health laboratories (SPHLs) requested participating clinical laboratories submit all Enterobacterales from all specimen sources during the surveillance period that were resistant to any carbapenem (Morganellaceae required resistance to doripenem, ertapenem, or meropenem) or were CP based on phenotypic or genotypic testing at the clinical laboratory. SPHLs performed species identification, phenotypic carbapenemase production testing, and molecular testing for carbapenemases to identify CP-CRE. Isolates were categorized as CP if they demonstrated phenotypic carbapenemase production and ≥1 carbapenemase gene (bla KPC, bla NDM, bla VIM, bla IMP, or bla OXA-48-like) was detected. RESULTS: SPHLs tested 868 CRE isolates, 127 (14.6%) were from eight LCG. Overall, 195 (26.3%) EsKE isolates were CP-CRE, compared with 24 (18.9%) LCG isolates. LCG accounted for 24 (11.0%) of 219 CP-CRE identified. Citrobacter spp. was the most common CP-LCG; the proportion of Citrobacter that were CP (11/42, 26.2%) was similar to the proportion of EsKE that were CP (195/741, 26.3%). Five of 24 (20.8%) CP-LCG had a carbapenemase gene other than bla KPC. CONCLUSIONS: Participating sites would have missed approximately 1 in 10 CP-CRE if isolate submission had been limited to EsKE genera. Expanding mechanism testing to additional genera could improve detection and prevention efforts.

Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016.

BACKGROUND: While naloxone, the overdose reversal medication, has been available for decades, factors associated with its availability through pharmacies remain unclear. Studies suggest that policy and pharmacist beliefs may impact availability. Indiana passed a standing order law for naloxone in 2015 to increase access to naloxone. OBJECTIVE: To identify factors associated with community pharmacy naloxone stocking and dispensing following the enactment of a statewide naloxone standing order. METHODS: A 2016 cross-sectional census of Indiana community pharmacists was conducted following a naloxone standing order. Community, pharmacy, and pharmacist characteristics, and pharmacist attitudes about naloxone dispensing, access, and perceptions of the standing order were measured. Modified Poisson and binary logistic regression models attempted to predict naloxone stocking and dispensing, respectively. RESULTS: Over half (58.1%) of pharmacies stocked naloxone, yet 23.6% of pharmacists dispensed it. Most (72.5%) pharmacists believed the standing order would increase naloxone stocking, and 66.5% believed it would increase dispensing. Chain pharmacies were 3.2 times as likely to stock naloxone. Naloxone stocking was 1.6 times as likely in pharmacies with more than one full-time pharmacist. Pharmacies where pharmacists received naloxone continuing education in the past two years were 1.3 times as likely to stock naloxone. The attempted dispensing model yielded no improvement over the constant-only model. CONCLUSIONS: Pharmacies with larger capacity took advantage of the naloxone standing order. Predictors of pharmacist naloxone dispensing should continue to be explored to maximize naloxone access.

Against the Odds: Syringe Exchange Policy Implementation in Indiana.

Indiana recently passed legislation allowing local governments to establish syringe exchanges. While the effectiveness of syringe exchange programming is established, there is a dearth of studies about associated policy adoption and implementation. This study documents the experiences of 24 Indiana counties engaged in the process of establishing syringe exchange programming under new state law. A mixed method, qualitative, exploratory case study was conducted from May 2015 to April 2016. We observed rapid and widespread policy adoption interest, and yet counties reported significant policy ambiguity, epidemiologic and resource capacity issues. The emergence of health commons involving information and tangible resource sharing networks allowed institutional rearrangement in the midst of resource scarcity; however, such rearrangement appeared to be a central threat to policy adoption and implementation given state structural barriers. The emerging commons could be a critical policy success factor, as it would achieve efficiencies not possible in the current resource environment, and can help achieve institutional rearrangement for the improvement of population health. Several recommendations for improvement are offered.

A double blind, placebo controlled study of piroxicam in the management of acute musculoskeletal disorders.

General Practitioners from the United Kingdom produced data on 1,282 patients with acute soft tissue injury treated with either piroxicam (Feldene) or matching placebo for a period of up to two weeks. The dosage of piroxicam was 40 mg for the first 2 days and 20 mg daily thereafter. Clinical assessment included pain, swelling, limitation of active and passive movement and overall assessment of efficacy and toleration. Piroxicam was significantly better than placebo in improving patient signs and symptoms, and in its overall efficacy (P less than 0.001); 87% of piroxicam treated patients had excellent or good responses, compared to 53% of placebo treated patients. On analysis of four of the most commonly occurring diagnoses (injuries of ankle, knee, shoulder, back) patients with moderate or severe pain showed a significant improvement on treatment with piroxicam. Physicians' overall assessment of toleration showed no evidence of differences between treatments. Over 90% of patients in both treatment groups had good or excellent toleration. Withdrawals due to side effects were 3% and 2.5% respectively for piroxicam and placebo treated patients.

Screening for impaired visual acuity in middle age in general practice.

Screening for impaired distant visual acuity was one component of a controlled trial of multiphasic screening in middle age carried out in two general practices. The prevalence of impaired visual acuity (6/18 or worse in the better eye) at the initial screening in 1967 was 9.6% overall, ranging from 5.9% in people aged 40-49 years to 16.3% in those aged over 60. The question "Do you have difficulty seeing distant objects?" had a low sensitivity and high specificity, rendering it unsatisfactory for use in mass population screening for visual impairment. The prevalences of impaired visual acuity in the screening and control groups at the survey in 1972 showed no significant differences in any age group. Mass screening for defects of visual acuity in the course of a multiphasic examination is thus unlikely to reduce the prevalence of impaired distant visual acuity in the community.

A long-term controlled trial of screening for hypertension in general practice.

A controlled trial was undertaken to evaluate the practical consequences of screening in general practice. Of 2420 people aged 40-64 years examined in 1967-68, 191 (7.9%) had previously been told, at some time, that they had raised blood-pressure, other than during pregnancy. However, only 77 (3-2%) had any record of current antihypertensive treatment. Screening resulted in a further 50 persons (2-1%) being newly diagnosed as hypertensive in 1967-68 and a further 9 in 1969-70. Antihypertensive treatment was given to 21 of these immediately following diagnosis, while the treatment was adjusted in 23 of those already known to be hypertensive. In 1972-73 the blood-pressures of the screening population were directly compared with the control group. No significant differences in the distributions of their blood-pressure levels were observed. Over 95% of the new hypertensives discovered by the screening process in the control group in 1972-73 had visited their general practitioners for some reason during the previous five years. This suggests that "case-finding" by general practitioners would be more cost-effective than setting up separate blood-pressure screening clinics. However, the results of this study indicate that we need to know more about how raised blood-pressure can be successfully controlled over a long time, before any mass screening programmes can be actively encouraged.