Impact of Beta-Lactam Allergies on Selection of Antimicrobials in an Inpatient Setting Among Veteran Population.

PURPOSE: Beta-lactam antibiotics are among the most common and widely used antibiotics. However, reported allergy to this class of antibiotics is also common, leading to the use of alternative broad-spectrum antibiotics by healthcare providers. This has led to the emergence of various negative health outcomes. The purpose of the study is to investigate the impact of using alternative antibiotics secondary to a beta-lactam allergy among U.S. veterans who have otherwise multiple comorbidities. METHODS: This retrospective observational analysis was conducted over a 5-year period (January 1, 2011 to December 31, 2016) at the Memphis Veterans Affairs Medical Center (VAMC). Admitted patients with a documented beta-lactam allergy were categorized to preferred or non-preferred status based on initial antibiotic therapy antibiotic, allergy history, published guidelines, and local antibiogram. Preferred therapy was defined as the optimal antibiotic treatment for a given indication based on patient allergy history, published Infectious Disease Society of America guidelines, and local antibiogram of Memphis VAMC. The therapy was classified as "non-preferred" if it did not satisfy the preferred therapy criteria. Non-preferred treatments were further assessed for appropriateness based on indication and patient-specific factors. Chi-square and Fisher's exact tests were conducted to find a difference in rates of negative sequelae among patients receiving preferred vs. non-preferred treatments and appropriate vs. inappropriate treatments. FINDINGS: Of the 1806 admissions identified, data were collected on 95 unique patients with 147 different antibiotic regimens. There were 68 (52%) preferred treatment regimens and 64 (48%) non-preferred treatment regimens. Of the 64 non-preferred treatments, 43 (67%) were inappropriate. There was a statistically significant decrease in the number of adverse drug events and in the combined negative sequelae outcome among patients receiving preferred therapy vs. non-preferred therapy (2 vs. 12; P < .01 and 11 vs. 23; P < .01, respectively). IMPLICATIONS: The receipt of non-preferred antibiotic therapy among veterans with a recorded beta-lactam allergy may be associated with an increased risk of developing negative outcomes. Among military personnel, removing unnecessary beta-lactam allergies would improve readiness with optimal antibiotic choices and avoidance of unnecessary risks, expediting return to full duty.

Safety Outcomes of Atorvastatin 80 mg Versus Atorvastatin 40 mg in a Veteran Population.

Background: High-intensity atorvastatin dosing may lead to a greater incidence of adverse events, subsequently leading to discontinuation and suboptimal risk reduction for major adverse cardiovascular events. No previous studies exist investigating the safety of high-intensity atorvastatin therapy among a veteran population. Objective: To evaluate the safety profile of high-intensity atorvastatin in the veteran population. Methods: This was a retrospective observational study conducted on patients newly prescribed atorvastatin 80 or 40 mg daily at the Memphis Veterans Affairs Medical Center. The primary outcome was incidence of adverse drug events. Secondary outcomes include incidence of high-intensity atorvastatin discontinuation and change of lipid panel values. Results: A total of 205 veterans were analyzed among atorvastatin 80 mg daily (n = 103) and atorvastatin 40 mg daily (n = 102) groups. Of 40 adverse events reported, 23 events occurred with atorvastatin 80 mg and 17 events with atorvastatin 40 mg (P = 0.31). Myalgia (11% vs 7%; P = 0.33) and weakness (12% vs 9%; P = 0.51) were commonly reported events among both cohorts. Rates of discontinuation of high-intensity atorvastatin therapy were similar between cohorts (26% vs 15%; P = 0.45). No statistically significant differences in lipid profile reductions were found. Conclusion and Relevance: Atorvastatin 80 mg daily was well tolerated with similar incidence of discontinuation and reduction of lipid panel values compared with atorvastatin 40 mg daily in a veteran population. This study provides a direct comparison of safety outcomes for high-intensity atorvastatin doses among veterans to highlight the importance of clinician-patient discussion on statin-related adverse effects compared with desired efficacy when considering initiation of therapy.

Characterizing the Safety Profile of Apixaban Versus Warfarin in Moderate to Severe Chronic Kidney Disease at a Veterans Affairs Hospital.

Background: Warfarin has been the cornerstone of therapy for patients with stage 4 and 5 chronic kidney disease (CKD) requiring anticoagulation. These patients were omitted from landmark clinical trials involving apixaban. Apixaban's safety profile is still largely unclear in this population. Objectives: To compare major bleeding, secondary bleeding outcomes, stroke, and thromboembolism in veterans with CKD stage 4, with CKD stage 5, and on dialysis on apixaban or warfarin. Methods: A retrospective chart review identified veterans with CKD stage 4 and stage 5, and on dialysis who received either apixaban or warfarin from 2013 to 2019 at the Memphis Veterans Affairs Medical Center. The primary outcome was incidence of major bleeding. Secondary outcomes were clinically relevant nonmajor and minor bleeding, composite bleeding, venous thromboembolism (VTE), and stroke. Results: A total of 111 patients were included in this study (warfarin group, n = 57; apixaban group, n = 54). Primary and secondary outcomes were analyzed using the χ2 or Fisher exact tests as appropriate. There was no difference in major bleeding between groups (14% vs 7%, P = 0.362). There were increased rates of minor bleeding (26% vs 6%, P = 0.004) and composite bleeding (46% vs 20%, P = 0.004) in patients receiving warfarin. There were no differences in rates of stroke or VTE between the 2 groups. Conclusion and Relevance: There was no difference in major bleeding in patients who received apixaban compared with warfarin. Apixaban may be a reasonable alternative to warfarin in veterans with CKD stage 4 and 5, including those on dialysis.