Urine culture guided antibiotic interventions: A pharmacist driven antimicrobial stewardship effort in the ED.

BACKGROUND: Antibiotics are overprescribed for abnormal urine tests including asymptomatic bacteriuria (AB), contributing to rising antimicrobial resistance rates. Pharmacists reviewed urine cultures daily from emergency department (ED) encounters to assess antibiotic appropriateness. We studied antibiotic prescribing practices and assessed compliance to national guidelines, correlations with urine analysis (UA) components, and opportunities for antimicrobial stewardship in the ED. METHODS: This quality improvement project (QIP) was a prospective cohort study at a community hospital ED, with data collected from finalized urine cultures resulting October 30, 2014 through January 5, 2015. Analyses were conducted using Chi-squared and Fisher Exact tests and stepwise multiple logistic regression. RESULTS: Urine cultures from 457 encounters were reviewed, of which 136 met the inclusion criteria as non-pregnant and asymptomatic for urinary tract infection (UTI). 43% of 136 patients were treated with antibiotics, for a total of 426 antibiotic days. Pharmacist interventions for these patients resulted in 122/426 (29%) of potential antibiotic days saved. Factors found to significantly increase the odds of antibiotic prescribing in asymptomatic patients included presence of leukocyte esterase (OR=4.5, 95% CI: 1.2-17.2; p=0.03) or nitrites (OR=10.8, 95% CI: 1.7-68.1; p=0.01) in the urine and age≥75 (OR=3.5, 95% CI: 1.2-9.6, p=0.02). DISCUSSION: Pharmacist intervention in discontinuing or modifying antibiotics for asymptomatic patients with urine cultures reduced unnecessary antibiotic exposure and was a first step in antimicrobial stewardship efforts in the ED. Future work includes limiting urine tests and subsequent antibiotic therapy for non-pregnant asymptomatic patients.

Effectiveness of rifaximin and fluoroquinolones in preventing travelers' diarrhea (TD): a systematic review and meta-analysis.

BACKGROUND: Recent developments related to a safe and effective nonabsorbable antibiotic, rifaximin, and identification of postinfectious irritable bowel syndrome as a frequent sequela call for a need to reconsider the value of primary prevention of traveler's diarrhea (TD) with antibiotics. METHODS: Randomized, placebo-controlled, double-blind studies evaluating the effectiveness and safety of rifaximin or a fluoroquinolone chemoprophylaxis against TD were pooled using a random effects model and assessed for heterogeneity. RESULTS: The nine studies (four rifaximin and five fluoroquinolone) included resulted in pooled relative risk estimates of 0.33 (95% CI = 0.24-0.45, I2 = 3.1%) and 0.12 (95% CI = 0.07-0.20, I2 =0.0%), respectively. Similar rates of treatment emergent adverse events were found between antibiotic and placebo groups. CONCLUSIONS: This meta-analysis supports the effectiveness of antibiotics in preventing TD. However, further studies that include prevention of secondary chronic health outcomes among travelers to different geographic regions, and a formal risk-benefit analysis for antibiotic chemoprophylaxis, are needed.

Quantifying the effect of resin type and sterilization method on the degradation of ultrahigh molecular weight polyethylene after 4 years of real-time shelf aging.

Alternative sterilization methods including ethylene oxide, gas plasma, and gamma-radiation in an inert environment were implemented in the late 1990s, to limit oxidative degradation of ultrahigh molecular weight polyethylene (PE). There was also a simultaneous transition to PE resins that did not contain calcium stearate. Shelf storage duration of PE inserts following gamma-irradiation in air has been correlated to poor clinical performance and increased wear. This study aimed to determine how sterilization method and resin type influenced degradation of PE after 4 years of real-time shelf aging. It was hypothesized that gamma-irradiation and stearate containing resins would incur significantly more degradation than nonradiated, stearate-free resins. Gamma-irradiated PE samples in air and nitrogen had a significantly increased density and oxidation index, compared to nonirradiated PE after 4 years of shelf aging. Alternative sterilization methods such as ethylene oxide and gas plasma appeared to have significantly less oxidation regardless of PE resin type. A partial correlation demonstrated that density and oxidation index were not correlated (r(2) = 0.079) when examining the influence of sterilization method. The data supported that after 4 years of real-time shelf aging, the type of sterilization method had a larger influence on PE degradation than resin type.