An evaluation of antimicrobial prophylaxis for transrectal prostate biopsies: A potential stewardship target.

BACKGROUND: Transrectal prostate biopsy (TRPB) is a common procedure used to obtain a prostate biopsy. Although generally safe, complications may occur including infection. Preprocedural antimicrobial prophylaxis is recommended to minimize risk of subsequent infection. METHODS: This study is a retrospective chart review via the computerized patient record system from January 1, 2018 to February 28, 2022. The study included patients who underwent a TRPB at the Western New York, Syracuse, or Albany Stratton Veterans Affairs Healthcare Systems. RESULTS: This study included a total of 932 patients who underwent TRPB. Postoperative infection occurred in 3.2% (n = 30) of patients within 14days of the TRPB. Of the 30 patients who developed an infection, 30% (n = 9) resulted in bacteremia. For the 932 patients evaluated, 24 different antibiotic regimens were used, none of which followed guideline recommendations. None of the regimens were found to have an impact on rates of subsequent infection. CONCLUSIONS: The results of this study suggest a need for guideline adherence. There was no benefit to using the guideline-discordant regimens as they were not associated with a decreased risk of infection, and in many cases exposed patients to unnecessarily broad and prolonged antibiotic regimens.

Impact of doxycycline on Clostridioides difficile infection in patients hospitalized with community-acquired pneumonia.

BACKGROUND: Antibiotic use is a significant risk factor associated with Clostridioides difficile (C difficile) infection (CDI). Community-acquired pneumonia (CAP) is a common infection leading to hospital admission and the use of antibiotics that are highly associated with CDI. It has been proposed that doxycycline, a tetracycline antibiotic, may be protective against CDI. METHODS: A retrospective analysis was conducted in hospitalized patients in Veterans Affairs Hospitals across the United States to determine if doxycycline was associated with a decreased risk of CDI. The primary outcome was the development of CDI within 30 days of initiation of doxycycline or azithromycin, as part of a standard pneumonia regimen. RESULTS: Approximately 156,107 hospitalized patients who received care at a Veterans Affairs Hospital and were diagnosed with CAP during the study timeframe were included. A 17% decreased risk of CDI was identified with doxycycline compared to azithromycin when used with ceftriaxone for the treatment of pneumonia (P = .03). In patients who had a prior history of CDI, doxycycline decreased the incidence of CDI by 45% (odds ratio 0.55; P = .02). CONCLUSIONS: Doxycycline is associated with a lower risk of CDI compared to azithromycin when used for atypical coverage in CAP. Thus, patients who are at such risk may benefit from doxycycline as a first-line agent for atypical coverage, rather than the use of a macrolide antibiotic, if Legionella is not of concern.

Increased Myocardial Infarction Risk Following Herpes Zoster Infection.

Background: Myocardial infarction (MI) has been reported as a postinfection sequela of herpes zoster, but with limited data on incidence after zoster and protective effect of the zoster vaccine. This study investigates the risk of developing an MI 30 days postzoster, determines patient-specific risk factors, and investigates the impact of herpes zoster vaccination. Methods: This retrospective cohort study included patients who received care at a Veterans Affairs facility between 2015 and 2020. Time to MI was determined from either 30 days post-zoster infection (zoster cohort) or a primary care appointment (control cohort). Results: This study assessed a total of 2 165 584 patients. MI within 30 days occurred in 0.34% (n = 244) of the zoster cohort and 0.28% (n = 5782) of the control cohort (P = .0016). Patients with a documented herpes zoster infection during the study period were 1.35 times more likely to develop an MI within the first 30 days postinfection compared to the control cohort. Patients who received the recombinant zoster vaccine were less likely to have an MI postinfection (odds ratio, 0.82 [95% confidence interval, .74-.92]; P = .0003). Conclusions: Herpes zoster infection was associated with an increased risk of MI within the first 30 days postinfection. History of prior MI, male sex, age ≥50 years, history of heart failure, peripheral vascular disease, human immunodeficiency virus, prior cerebrovascular accident, and renal disease increased odds of MI 30 days postinfection with herpes zoster. Herpes zoster vaccination decreased the odds of developing an MI in patients aged ≥50 years.

Increased Stroke Risk Following Herpes Zoster Infection and Protection With Zoster Vaccine.

BACKGROUND: Studies evaluating stroke following varicella zoster virus (VZV) infection are limited, and the utility of zoster vaccination against this phenomenon is unclear. This study aimed to determine the risk of stroke 30 days following zoster infection and to evaluate the impact of zoster vaccinations on the risk of stroke in VZV-infected patients. METHODS: This retrospective case-control study was conducted from January 2010 to January 2020 utilizing nationwide patient data retrieved from the Veterans Affairs' Corporate Data Warehouse. RESULTS: A total of 2 165 505 patients ≥18 years of age who received care at a Veterans Affairs facility were included in the study, of whom 71 911 had a history of zoster infection. Zoster patients were found to have 1.9 times increased likelihood of developing a stroke within 30 days following infection (odds ratio [OR], 1.93 [95% confidence interval {CI}, 1.57-2.4]; P < .0001). A decreased risk of stroke was seen in patients who received the recombinant zoster vaccine (OR, 0.57 [95% CI, .46-.72]; P < .0001) or the live zoster vaccine (OR, 0.77 [95% CI, .65-.91]; P = .002). CONCLUSIONS: Patients had a significantly higher risk of stroke within the first month following recent herpes zoster infection. Receipt of at least 1 zoster vaccination was found to mitigate this increased risk. Vaccination may therefore be viewed as a protective tool against the risk of neurologic postinfection sequelae.

Risk factors associated with mortality in hospitalized patients with laboratory confirmed SARS-CoV-2 infection during the period of omicron (B.1.1.529) variant predominance.

BACKGROUND: SARS-CoV-2 Omicron variant has a high transmission rate. In December 2021, Omicron became the dominant variant and quickly accounted for majority of infections in the United States. Drug shortages have led to prioritization of patients for COVID-19 treatment based on risk factors for severe disease. METHODS: A retrospective analysis of hospitalized patients with COVID-19 infection at Veteran Affairs Healthcare System across the United States. The primary outcome was 14-day all-cause mortality after the first documented positive SARS-CoV-2 laboratory test. Odds ratios were generated from a multivariate logistic regression of significant factors. RESULTS: This study included 12,936 COVID-19 inpatients during a period of Omicron predominance. Age ≥ 65 years is a predictor of 14-day mortality among the vaccinated and unvaccinated population (OR 4.05, CI 3.06-5.45, P ≤ .0001). Triple vaccinated patients demonstrated a 52% decreased risk of death with COVID-19 infection (OR 0.48, CI 0.37-0.61, P ≤ .0001). Patients who were double vaccinated had a 39% decreased risk of death with COVID-19 infection (OR 0.61, CI 0.46-0.80, P = .003). CONCLUSION: Advanced age ≥ 65 is the greatest risk factor for mortality in hospitalized COVID-19 patients. COVID-19 vaccination, especially booster doses, was associated with a decreased risk of 14-day mortality compared to double vaccinated or non-vaccinated patients. Results of this study suggest that advanced age should be considered first for prioritization of COVID-19 treatments for Omicron.

Outcomes of multiple sclerosis patients admitted with COVID-19 in a large veteran cohort.

BACKGROUND: Given concerns over immune function, the decision whether to continue disease modifying therapy (DMT) in multiple sclerosis (MS) patients during the COVID-19 pandemic has been challenging, complicated by the risk of MS disease progression in the absence of treatment. METHODS: This retrospective analysis of patients treated for COVID-19 infection at veteran affairs healthcare systems across the United States, investigated 30-day all-cause mortality after first positive COVID-19 in patients with and without MS. We examined mortality risk impact of disease modifying therapy for MS, accounting for other relevant factors known to be associated with COVID-19 mortality. Patients were propensity score matched in a 1:20 fashion based on MS diagnosis. RESULTS: 49,737 COVID-19 inpatient cases were identified, of which 258 were diagnosed with MS. In the propensity score matched cohort, MS patients taking DMT (excluding those receiving anti-CD20 antibodies) had a lower odds of 30 day mortality (OR: 0.18 [95%CI: 0.00988-0.94] p=0.041). Similarly, in the unmatched cohort, patients on DMT had a lower risk of death (OR: 0.16 [95%CI: 0.01-0.82] p=0.023). There was no statistically significant difference in mortality between those with and without MS. In the propensity matched cohort, age over 65, heart failure, chronic kidney disease (CKD), and diabetes increased the risk of mortality while vaccination reduced the risk of mortality. CONCLUSION: Veteran patients with MS hospitalized for COVID-19 were less likely to die when taking DMTs (excluding those receiving anti-CD20 antibodies), accounting for other relevant factors. Results suggest that, in relation to the COVID-19 pandemic, not only is it safe to continue most DMTs in people with MS, but it may be beneficial given the decreased risk of COVID-19 mortality and decreased risk of MS disease progression.

Admissions and Mortality Related to Urinary Tract Infections in Male Veterans with Dementia.

Objective To examine mortality and hospital readmission rates in male veterans with dementia diagnosed with urinary tract infection (UTI) compared with patients without dementia. Design Retrospective cohort study. Setting Veterans Healthcare Systems (VA). Participants Male inpatients with a diagnosis of UTI who were treated at any VA Healthcare Center from January 1, 2009, to December 31, 2018. Interventions None. Main Outcome Measures Mortality and hospital readmission for patients with and without dementia at 30, 60, and 90 days from UTI diagnosis. Results 262,515 veterans admitted with UTI were analyzed, and 58,940 (22.5%) had dementia. The mean age for veterans with dementia was 80.0 +/- 9.7 years. Veterans with dementia experienced less mortality than patients without dementia at 30 days (8.3% vs 8.5%; P < 0.001), but more mortality at 60-day (4.9% vs 4.7%; P < 0.001) and 90-day (3.6% vs 3.3%; P < 0.001) intervals. Death was 20% less likely at 30 days in patients with dementia. Veterans with dementia were readmitted more than those without dementia at 30-day (18.4% vs 16.0%), 60-day (4.5% vs 2.8%), and 90-day (3.4% vs 2.5%) intervals; P < 0.0001. Conclusion Though patients with dementia are at an increased risk for death long-term, risk of death is less than those without dementia shortly following UTI diagnosis. This highlights the possibility that veterans with dementia may be hospitalized and diagnosed with UTIs when in actuality they have asymptomatic bacteriuria. Patients with dementia and UTI therefore represent an important group of geriatric patients that could benefit from the oversight of a senior care pharmacist to help prevent unnecessary treatment of asymptomatic bacteriuria.

Smoking status related to Covid-19 mortality and disease severity in a veteran population.

INTRODUCTION: Cigarette smoking is associated with development of significant comorbidities. Patients with underlying comorbidities have been found to have worse outcomes associated with Coronavirus Disease 2019 (Covid-19). This study evaluated 30-day mortality in Covid-19 positive patients based on smoking status. METHODS: This retrospective study of veterans nationwide examined Covid-19 positive inpatients between March 2020 and January 2021. Bivariate analysis compared patients based on smoking history. Propensity score matching adjusted for age, gender, race, ethnicity, Charlson comorbidity index (0-5 and 6-19) and dexamethasone use was performed. A multivariable logistic regression with backwards elimination and Cox Proportional Hazards Ratio was utilized to determine odds of 30-day mortality. RESULTS: The study cohort consisted of 25,958 unique Covid-19 positive inpatients. There was a total of 2,995 current smokers, 12,169 former smokers, and 8,392 non-smokers. Death was experienced by 13.5% (n = 3503) of the cohort within 30 days. Former smokers (OR 1.15; 95% CI, 1.05-1.27) (HR 1.13; 95% CI, 1.03-1.23) had higher risk of 30-day mortality compared with non-smokers. Former smokers had a higher risk of death compared to current smokers (HR 1.16 95% CI 1.02-1.33). The odds of death for current vs. non-smokers did not significantly differ. CONCLUSION: Compared to veteran non-smokers with Covid-19, former, but not current smokers with Covid-19 had a significantly higher risk of 30-day mortality.

Trends in beta-hemolytic Streptococcus infections within Veterans' Affairs medical centers from 2009 to 2018.

OBJECTIVE: The purpose of this study was to describe the recent trends of invasive and noninvasive ß-hemolytic Streptococcus cultures in the Veterans' Affairs (VA) cohort from 2009 to 2018. DESIGN: Retrospective cohort study from January 1, 2009, to January 1, 2019. SETTING: Veterans' Affairs medical centers. PATIENTS OR PARTICIPANTS: All patients aged 18 years and older with cultures positive for ß-hemolytic Streptococcus at a VA facility were included in the study. INTERVENTION(S): Data were retrieved from the VA Corporate Data Warehouse using structure query language through the SQL Server Management Studio software. RESULTS: Between 2009 and 2018, there were 40,625 patients with cultures with ß-hemolytic Streptococcus. The median age was 64 years (interquartile range [IQR], 55-71) and the median Charlson comorbidity index was 4 (IQR, 2-7). Distributions for each type of ß-hemolytic Streptococcus based on site of culture are provided. The 30-day all-cause mortality rate from all invasive ß-hemolytic Streptococcus cases was 2.3%, and the 90-day all-cause mortality rate was 4.4%. The 30- and 90-day all-cause mortality rates for Streptococcus cases were higher for group A (3.9% and 6.1% respectively) and for groups C and G combined (3.2% and 6.1%, respectively) than for group B (2.0% and 4.0%, respectively). CONCLUSIONS: Trends of cultures for invasive and noninvasive ß-hemolytic Streptococcus suggest an association with disease and mortality. The burden associated with ß-hemolytic Streptococcus infections should not be underestimated.

Societal factors contributing to infections caused by Chlamydia trachomatis and Neisseria gonorrhoeae in a veteran population.

BACKGROUND: Veterans have a higher incidence of sexually transmitted infections (STIs) compared to the general population. The objective of this study is to evaluate the association of societal factors on the risk of chlamydia or gonorrhea. METHODS: This retrospective cohort study evaluated data from Veteran Health Administration. Patients tested for chlamydia or gonorrhea between January 2009 and January 2019 were included. Descriptive statistics and regression were used to evaluate societal factors. RESULTS: A total of 1,232,173 tests for chlamydia or gonorrhea were performed. There were 51,987 (4.2%) positive cases with 74.18% for chlamydia and 24.96% for gonorrhea. In 13.6% of veterans with reported military sexual trauma, there was no difference in risk of positivity (p = 0.39). Veterans with a history of combat had lower odds of testing positive (OR, 0.94; 95% CI, 0.91-0.97). Tests in veterans who were married had a 24% less chance of positivity (OR, 0.76; 95% CI, 0.74-0.79) compared to tests in divorced veterans. Positive number of cases increased each year. CONCLUSION: Sexually transmitted infections are a growing concern. Gender, age, ethnicity, marital status, and race are societal identifiers which influence likelihood of STI acquisition.

Risk Factors for Mortality in an Older Veteran Population With infective Endocarditis.

OBJECTIVE: To determine 30-day and 1-year mortality in patients treated for infective endocarditis (IE) in a VA population. The secondary objective was to identify risk factors for increased risk of mortality in veterans diagnosed with IE. DESIGN: A retrospective cohort study. SETTING: Veterans Affairs Western New York Healthcare System PARTICIPANTS: Patients who had a diagnosis of IE between the years 2005 and 2016. Patients were identified via International Classification of Diseases (ICD) codes. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Factors for death and survival were compared using a bivariate analysis. Significant factors were built into a multivariate logistic regression analysis to determine risk factors for death at 30 days and 1 year. RESULTS: Between 2005 and 2016, there were 153 patients with IE. All-cause mortality at 30 days was 14% versus 39% at 1 year. Patients were more likely to die at 1 year with higher Pitt Bacteremia Scores, older age, and lower number of minor criteria according to Duke Criteria. Comorbidities were similar between groups. CONCLUSIONS: Older patients with higher Pitt Bacteremia Scores and lower numbers of minor criteria are more likely to experience mortality at one year. Given the high rates of death at one year, close monitoring, even after completion of therapy may be necessary in older patients. Senior care pharmacists are in a unique position to monitor these patients.

Sputum susceptibilities in a nationwide veteran cohort.

BACKGROUND: Respiratory infections are one of the most common causes of morbidity and mortality. This study examined antimicrobial susceptibility of common respiratory isolates from veterans. METHODS: Sputum culture data from the Veteran Health Administration were obtained retrospectively between January 2009 and 2019. Cumulative antibiograms were constructed for bacterial isolate susceptibility. RESULTS: Sputum and bronchial cultures from approximately 10,345 veterans were included each year. Haemophilus influenzae has maintained high levels of susceptibility to third generation cephalosporins from 2009 (99.7%) to 2018 (97.2%). Third generation cephalosporin susceptibilities amongst Klebsiella pneumoniae have trended upward from 2009 to 2018 as well (79.1% vs 86.4%). In Pseudomonas aeruginosa isolates, there has been an increase in susceptibility rates to cefepime from 2009 to 2018 (79.6%, to 86.6%), gentamicin (81.5% to 89.1%), and piperacillin/tazobactam (86.5% to 90%). Fluoroquinolone susceptibilities amongst Escherichia coli have remained low but stable between 2009 and 2018. Third generation cephalosporin susceptibilities for S. pneumoniae improved slightly from 92.2% to 95% between 2009 and 2018 while susceptibility to azithromycin trended down slightly from 56.8% in 2009 to 51.7% in 2018 for S. pneumoniae. DISCUSSION: The antibiogram of sputum isolates from the VA Healthcare System were examined to determine changes in patterns of resistance over a decade of use. CONCLUSIONS: This large-scale study investigated nationwide sputum culture susceptibility trends. Avoidance of macrolides for empiric treatment of community acquired pneumonia and avoidance of fluoroquinolones for empiric treatment of hospital acquired or ventilator associated pneumonia may be warranted based on susceptibility trends.

Antimicrobial susceptibility trends for urinary isolates in the veteran population.

BACKGROUND: Guidance on empiric treatment for urinary tract infections (UTIs) is lacking for the male population which comprises much of the Veteran population in the United States. This study evaluated susceptibility trends in antimicrobials used for treatment of UTIs in the inpatient and outpatient Veteran population nationwide. METHODS: Urine culture data was retrospectively obtained from Corporate Data Warehouse. All urine cultures from Veteran Health Administration patients 18 years of age or older who were treated at any VA health care center in the years 2009 and 2018 were eligible. Antibiograms were constructed for bacterial isolate susceptibility. RESULTS: In 2009 and 2018 isolates from 54,788 and 58,983 Veterans were analyzed, respectively. Escherichia coli was the most common bacteria isolated. For ceftriaxone, E coli susceptibilities were relatively high but trended downward from 2009 to 2018. Common urinary pathogen susceptibilities remained low for fluoroquinolones and trimethoprim-sulfamethoxazole. DISCUSSION: Empiric therapy for Veterans with UTIs should be based on local susceptibility patterns as previously recommended first-line agents have fallen out of favor due to increasing resistance rates. CONCLUSIONS: Both inpatient and outpatient stewardship is needed to ensure appropriate treatment, as viable treatment options for UTIs are becoming increasingly limited.

An Evaluation of Antimicrobial Prophylaxis for Dental Procedures at a Veterans Healthcare System; A Role for Senior Care Pharmacists?

OBJECTIVE: The primary objective of this study was to determine the prevalence of appropriate use of antibiotics before a dental procedure.
DESIGN: Retrospective cohort study.
SETTING: Veterans Healthcare Systems.
PARTICIPANTS: Veterans who filled outpatient prescriptions for antimicrobial dental prophylaxis at the Veterans Administration Western New York Healthcare System from December 1, 2017, through October 1, 2019.
INTERVENTIONS: None.
MAIN OUTCOME MEASURES: Use of antibiotic dental prophylaxis was deemed appropriate if in accordance with guideline recommendations. Descriptive statistics were used to summarize data.
RESULTS: A total of 130 veterans receiving antibiotics for dental prophylaxis were included in this evaluation. Of those who were included, only 16.9% received appropriate antibiotic dental prophylaxis. Patients with a prosthetic joint were significantly more likely to be inappropriately prescribed antibiotics for dental prophylaxis. Approximately 87% of patients who were inappropriately prescribed antibiotic prophylaxis had prosthetic joints (P < .0001).
CONCLUSION: Most antibiotics for dental prophylaxis are prescribed inappropriately. The large amount of inappropriately used antibiotics in this study highlights the need for dental stewardship in our veteran population. Antibiotics for dental prophylaxis therefore represent an important stewardship target in the outpatient setting. This may be an ideal opportunity for senior care pharmacists to intervene upon.

Antibiotic prescribing in the emergency department versus primary care: Implications for stewardship.

OBJECTIVE: This study sought to compare the appropriateness of antibiotic prescribing by drug, dose, duration, and indication between the emergency department (ED) and primary care (PC) within the Veterans Affairs Western New York Healthcare System (VAWNYHCS) to aid in focusing antimicrobial stewardship efforts. DESIGN: In this prospective observational cohort study, patients were identified using electronic alerts at the time of antibiotic prescribing. Prescriptions were retrospectively analyzed for appropriateness of antibiotic indication, drug choice, dose, and duration on the basis of current guideline recommendations. Data were compared between the ED and PC to determine the impact of visit location on prescribing habits. Baseline characteristics were compared using descriptive statistics, and a multivariable analysis was performed to identify statistically significant risk factors for inappropriate prescribing. SETTING AND PARTICIPANTS: Patients prescribed outpatient antibiotics at the VAWNYHCS ED and PC settings between June 2017 and February 2018. OUTCOME MEASURES: Appropriateness of antibiotic prescribing by drug, dose, duration, and indication between the ED and PC settings. RESULTS: The cohort included 1566 antibiotic prescriptions (ED = 488, PC = 1078). The appropriate drug, dose, and duration for antibiotics prescribed in the ED versus PC were 63.1% versus 43.4% (P < 0.001), 88.1% versus 88.2% (P = 0.953), and 86.1% versus 71.1% (P < 0.001), respectively. Azithromycin was the most inappropriately prescribed antibiotic in both the ED (37.8%) and PC (49.0%). Two factors predicted whether patients received the correct antibiotic empirically: location of the visit and antibiotic allergy. Overall, 56.6% of ED prescriptions and 82% of PC prescriptions were inappropriate with respect to at least 1 component. CONCLUSION: Stewardship is needed in both the ED and PC settings. However, initial efforts should be focused on PC because this setting had a statistically significant amount of inappropriate antibiotic prescribing. Pharmacist-led education and interventions should focus on the determination of drug, duration, and indication for the use of antibiotics.

Outpatient antimicrobial stewardship: Targets for urinary tract infections.

BACKGROUND: Urinary tract infections (UTIs) are common. Outpatient antimicrobial stewardship programs are emerging and a focused approach to UTIs is needed to help guide programs. METHODS: Data were collected by retrospective chart review of outpatients using encounters from January 2005 to March 2018. Antibiotic therapy was indicated if at least one UTI symptom was present. Antibiotic therapy was appropriate if consistent with guidelines and culture results. Factors that differed significantly (P <.05) between the comparator groups were built into a multivariable logistic regression model to determine factors associated with inappropriate prescribing. RESULTS: A total of 607 outpatients were included, of which approximately 68% were treated inappropriately. Inappropriate regimens consisted of 50.9% (n = 309) incorrect durations, 35.1% (n = 213) incorrect choice of antibiotic, and 12.4% (n = 75) incorrect doses. Ten percent of patients developed a reinfection within 30 days. Recurrence of UTI with the same pathogen within 30 days occurred in 5.1%. Catheter use and advanced age are both risk factors for recurrence and inappropriate treatment. CONCLUSIONS: Outpatient antibiotic prescribing for UTIs is suboptimal. Stewardship programs should focus on patients with catheters and of advanced age as they are often inappropriately treated.

Outpatient antimicrobial stewardship: Optimizing patient care via pharmacist led microbiology review.

BACKGROUND: Cultures are often taken in the outpatient setting but results are not acted upon, leading to unnecessary re-presentations to the health care setting. METHODS: This study was a prospective study with interventions made between January 1, 2018, and January 1, 2019. Cultures were reviewed to ensure appropriate antimicrobial coverage. The objective was to compare outcomes with accepted versus rejected interventions. Descriptive statistics were used to summarize data. RESULTS: A total of 7,360 antibiotic orders were reviewed by the infectious diseases pharmacists. Pharmacists intervened on 20.1% (n = 194) of encounters with related cultures. Interventions were most frequent in the emergency department (42%). Ciprofloxacin required the most interventions (26%), followed by third-generation cephalosporins (22%). The intervention acceptance rate was 76%, which was associated with decreased rates of 30-day treatment failure (5% vs 28%, P < .001) and 30-day admission (0.7% vs 11%, P = .001), when interventions were accepted rather than rejected. DISCUSSION: Approximately 20% of patients required intervention. Culture review services may be beneficial in a variety of outpatient settings. Outpatient stewardship literature is limited, and our study found a decrease in admission and treatment failure. CONCLUSIONS: Microbiology review and intervention positively impacted care for outpatients. Intervention was associated with significantly decreased rates of treatment failure and admission when interventions were accepted.

Determining the Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening in Antimicrobial Stewardship.

BACKGROUND: Treatment of suspected methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of many antibiotic regimens; however, there is associated toxicity. The Department of Veterans Affairs (VA) hospitals screen each patient for MRSA nares colonization on admission and transfer. The objective was to determine the negative predictive value (NPV) of MRSA screening in the determination of subsequent positive clinical culture for MRSA. High NPVs with MRSA nares screening may be used as a stewardship tool. METHODS: This was a retrospective cohort study across VA medical centers nationwide from 1 January 2007 to 1 January 2018. Data from patients with MRSA nares screening were obtained from the VA Corporate Data Warehouse. Subsequent clinical cultures within 7 days of the nares swab were evaluated for the presence of MRSA. Sensitivity, specificity, positive predictive values, and NPVs were calculated for the entire cohort as well as subgroups for specific culture sites. RESULTS: This cohort yielded 561 325 clinical cultures from a variety of anatomical sites. The sensitivity and specificity for positive MRSA clinical culture were 67.4% and 81.2%, respectively. The NPV of MRSA nares screening for ruling out MRSA infection was 96.5%. The NPV for bloodstream infections was 96.5%, for intraabdominal cultures it was 98.6%, for respiratory cultures it was 96.1%, for wound cultures it was 93.1%, and for cultures from the urinary system it was 99.2%. CONCLUSION: Given the high NPVs, MRSA nares screening may be a powerful stewardship tool for deescalation and avoidance of empirical anti-MRSA therapy.

Fact versus Fiction: a Review of the Evidence behind Alcohol and Antibiotic Interactions.

Many antibiotics carry caution stickers that warn against alcohol consumption. Data regarding concurrent use are sparse. An awareness of data that address this common clinical scenario is important so health care professionals can make informed clinical decisions and address questions in an evidence-based manner. The purpose of this systematic review was to determine the evidence behind alcohol warnings issued for many common antimicrobials. The search was conducted from inception of each database to 2018 using PubMed, Medline via Ovid, and Embase. It included studies that involved interactions, effects on efficacy, and toxicity/adverse drug reactions (ADR) due to concomitant alcohol consumption and antimicrobials. All interactions were considered in terms of three components: (i) alteration in pharmacokinetics/pharmacodynamics (PK/PD) of antimicrobials and/or alcohol, (ii) change in antimicrobial efficacy, and (iii) development of toxicity/ADR. Available data support that oral penicillins, cefdinir, cefpodoxime, fluoroquinolones, azithromycin, tetracycline, nitrofurantoin, secnidazole, tinidazole, and fluconazole can be safely used with concomitant alcohol consumption. Data are equivocal for trimethoprim-sulfamethoxazole. Erythromycin may have reduced efficacy with alcohol consumption, and doxycycline may have reduced efficacy in chronic alcoholism. Alcohol low in tyramine may be consumed with oxazolidinones. The disulfiram-like reaction, though classically associated with metronidazole, occurs with uncertain frequency and with varied severity. Cephalosporins with a methylthiotetrazole (MTT) side chain or a methylthiodioxotriazine (MTDT) ring, ketoconazole, and griseofulvin have an increased risk of a disulfiram-like reaction. Alcohol and antimicrobial interactions are often lacking evidence. This review questions common beliefs due to poor, often conflicting data and identifies important knowledge gaps.